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van der Pol JA, Allaart CF, Lems W, van der Kooij SM, Huizinga TWJ, Bergstra SA. Prednisone use, disease activity and the occurrence of hyperglycaemia and diabetes in patients with early rheumatoid arthritis: a 10-year subanalysis of the BeSt study. RMD Open 2024; 10:e004246. [PMID: 38688692 PMCID: PMC11086516 DOI: 10.1136/rmdopen-2024-004246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 04/17/2024] [Indexed: 05/02/2024] Open
Abstract
OBJECTIVES To assess whether prednisone use and/or disease activity score (DAS) are associated with the development of hyperglycaemia and diabetes in rheumatoid arthritis (RA). METHODS We included 504 non-diabetic early RA patients from the BeSt study (Dutch acronym for treatment strategies). Patients were randomised to four DAS-steered treatment arms and followed for 10 years. The associations between DAS and prednisone use with glucose levels and the occurrence of hyperglycaemia over time were assessed with linear and logistic mixed effects regression models. Development of diabetes was analysed with Cox regression. Sensitivity analyses were performed in patients who had a first episode of hyperglycaemia. RESULTS 31 of 504 patients (6.2%) with a mean age of 54 years developed diabetes during follow-up; 11 of these (35%) had received prior treatment with prednisone. Prednisone use was not associated with development of hyperglycaemia or diabetes after correction for multiple testing in main or sensitivity analyses. In the main analyses, DAS was significantly associated with development of diabetes (HR 1.802 per 1 point DAS increase, 95% CI 1.284 to 2.529) but not with glucose levels nor hyperglycaemia. In patients with previous hyperglycaemia, DAS was associated with glucose levels, recurrence of hyperglycaemia and diabetes. CONCLUSIONS In non-diabetic early RA patients, the use of prednisone was not associated with developing hyperglycaemia or diabetes. However, high DAS increased the risk of diabetes. Potential risks associated with prednisone use may have been mitigated by its effect on DAS.
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Affiliation(s)
| | - Cornelia F Allaart
- Department of Rheumatology, Leiden University Medical Center, Leiden, Netherlands
| | - Willem Lems
- Rheumatology, VU Medical Center, Amsterdam, Netherlands
| | | | - Tom W J Huizinga
- Department of Rheumatology, Leiden University Medical Center, Leiden, Netherlands
| | - Sytske Anne Bergstra
- Department of Rheumatology, Leiden University Medical Center, Leiden, Netherlands
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2
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Cho JH, Suh S. Glucocorticoid-Induced Hyperglycemia: A Neglected Problem. Endocrinol Metab (Seoul) 2024; 39:222-238. [PMID: 38532282 PMCID: PMC11066448 DOI: 10.3803/enm.2024.1951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Revised: 02/19/2024] [Accepted: 02/20/2024] [Indexed: 03/28/2024] Open
Abstract
Glucocorticoids provide a potent therapeutic response and are widely used to treat a variety of diseases, including coronavirus disease 2019 (COVID-19) infection. However, the issue of glucocorticoid-induced hyperglycemia (GIH), which is observed in over one-third of patients treated with glucocorticoids, is often neglected. To improve the clinical course and prognosis of diseases that necessitate glucocorticoid therapy, proper management of GIH is essential. The key pathophysiology of GIH includes systemic insulin resistance, which exacerbates hepatic steatosis and visceral obesity, as well as proteolysis and lipolysis of muscle and adipose tissue, coupled with β-cell dysfunction. For patients on glucocorticoid therapy, risk stratification should be conducted through a detailed baseline evaluation, and frequent glucose monitoring is recommended to detect the onset of GIH, particularly in high-risk individuals. Patients with confirmed GIH who require treatment should follow an insulin-centered regimen that varies depending on whether they are inpatients or outpatients, as well as the type and dosage of glucocorticoid used. The ideal strategy to maintain normoglycemia while preventing hypoglycemia is to combine basal-bolus insulin and correction doses with a continuous glucose monitoring system. This review focuses on the current understanding and latest evidence concerning GIH, incorporating insights gained from the COVID-19 pandemic.
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Affiliation(s)
- Jung-Hwan Cho
- Department of Internal Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
| | - Sunghwan Suh
- Department of Internal Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
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3
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Kim JG, Jang S, Lee J, Ju JH, Kim WU, Park SH, Kwok SK. A single-centre retrospective study of factors affecting steroid-free remission of immunoglobulin G4-related disease conducted in South Korea: A notable outcome after complete resection. Mod Rheumatol 2024; 34:614-620. [PMID: 37022150 DOI: 10.1093/mr/road034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 03/03/2023] [Accepted: 03/23/2023] [Indexed: 04/07/2023]
Abstract
OBJECTIVES Few studies have examined factors affecting steroid-free remission (SFR) in patients with immunoglobulin G4-related disease (IgG4-RD). The aim of this study was to investigate clinical factors affecting SFR in IgG4-RD. METHODS The medical records of 68 patients who met the 2020 revised comprehensive diagnostic criteria for IgG4-RD were reviewed retrospectively. SFR was defined as remission maintained for at least 6 months without corticosteroids. Cox regression analysis was performed to examine the associations between SFR and various clinical factors. The relapse rate after SFR was examined using the log-rank test. RESULTS After a median follow-up of 36 months, 30.9% (21/68) of patients with IgG4-RD achieved SFR. Multivariate Cox regression analysis revealed that IgG4-RD diagnosed by complete resection rather than by common diagnostic procedures was the only factor positively associated with SFR (hazard ratio, 7.41; 95% confidence interval, 2.23-24.60; P = .001). Furthermore, relapse after attainment of SFR was significantly less common in the group that underwent complete resection than in the group that did not undergo complete resection (log-rank P = .006). CONCLUSIONS Patients with IgG4-RD diagnosed by complete resection had a higher likelihood of achieving SFR and a lower rate of relapse after attaining SFR.
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Affiliation(s)
- Jung Gon Kim
- Division of Rheumatology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
- Division of Rheumatology, Department of Internal Medicine, Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Republic of Korea
| | - Sunhee Jang
- Division of Rheumatology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jennifer Lee
- Division of Rheumatology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Ji Hyeon Ju
- Division of Rheumatology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Wan-Uk Kim
- Division of Rheumatology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sung-Hwan Park
- Division of Rheumatology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Seung-Ki Kwok
- Division of Rheumatology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
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4
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Sarriyah JF, Alghamdi AS, Al-Otaibi NM, Abdulrahman BB, Aljaed KM. Prevalence of Steroid-Induced Hyperglycemia in King Abdulaziz Specialist Hospital, Taif City, Saudi Arabia. Cureus 2024; 16:e54430. [PMID: 38510914 PMCID: PMC10951554 DOI: 10.7759/cureus.54430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/18/2024] [Indexed: 03/22/2024] Open
Abstract
Background Hyperglycemia is a common side effect of high-dose steroid therapy in hospitalized patients. Objectives To assess the prevalence of hyperglycemia among hospitalized patients receiving steroid therapy. Methods A retrospective study was conducted among 245 patients. The inclusion criteria were patients undergoing steroid therapy and admitted to a single tertiary care hospital due to medical complications or exacerbation of the diseases they were suffering from. Data encompassing patient demographics, admission, discharge dates, comorbidities, medication histories, laboratory results (including blood glucose levels), and documented corticosteroid administrations were meticulously gathered from electronic health records (EHRs). A logistic regression model analysis was done to predict the risk factors of poor glycemic control among hospitalized patients. Results The prevalence of hyperglycemia among the patients who were on steroid therapy was 34.2%. About 70.7% of the patients who required insulin at the time of admission required >17 units, and the insulin requirement was significantly higher among patients who received dexamethasone compared to other steroids (p<0.05). Older age (>65 years) was found to be independently associated with poor glycemic control (p<0.05). Conclusion The study revealed that almost one-third of patients on steroid therapy had hyperglycemia. Monitoring of patients for hyperglycemia after beginning high-dose steroid therapy should be done.
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Affiliation(s)
- Jehan F Sarriyah
- Internal Medicine, King Abdulaziz Specialist Hospital, Taif, SAU
| | - Adel S Alghamdi
- Endocrinology, King Abdulaziz Specialist Hospital, Taif, SAU
| | | | | | - Kholoud M Aljaed
- Internal Medicine, King Abdulaziz Specialist Hospital, Taif, SAU
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5
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Pofi R, Caratti G, Ray DW, Tomlinson JW. Treating the Side Effects of Exogenous Glucocorticoids; Can We Separate the Good From the Bad? Endocr Rev 2023; 44:975-1011. [PMID: 37253115 PMCID: PMC10638606 DOI: 10.1210/endrev/bnad016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 04/25/2023] [Accepted: 05/26/2023] [Indexed: 06/01/2023]
Abstract
It is estimated that 2% to 3% of the population are currently prescribed systemic or topical glucocorticoid treatment. The potent anti-inflammatory action of glucocorticoids to deliver therapeutic benefit is not in doubt. However, the side effects associated with their use, including central weight gain, hypertension, insulin resistance, type 2 diabetes (T2D), and osteoporosis, often collectively termed iatrogenic Cushing's syndrome, are associated with a significant health and economic burden. The precise cellular mechanisms underpinning the differential action of glucocorticoids to drive the desirable and undesirable effects are still not completely understood. Faced with the unmet clinical need to limit glucocorticoid-induced adverse effects alongside ensuring the preservation of anti-inflammatory actions, several strategies have been pursued. The coprescription of existing licensed drugs to treat incident adverse effects can be effective, but data examining the prevention of adverse effects are limited. Novel selective glucocorticoid receptor agonists and selective glucocorticoid receptor modulators have been designed that aim to specifically and selectively activate anti-inflammatory responses based upon their interaction with the glucocorticoid receptor. Several of these compounds are currently in clinical trials to evaluate their efficacy. More recently, strategies exploiting tissue-specific glucocorticoid metabolism through the isoforms of 11β-hydroxysteroid dehydrogenase has shown early potential, although data from clinical trials are limited. The aim of any treatment is to maximize benefit while minimizing risk, and within this review we define the adverse effect profile associated with glucocorticoid use and evaluate current and developing strategies that aim to limit side effects but preserve desirable therapeutic efficacy.
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Affiliation(s)
- Riccardo Pofi
- Oxford Centre for Diabetes, Endocrinology and Metabolism, NIHR Oxford Biomedical Research Centre, University of Oxford, Churchill Hospital, Oxford OX3 7LE, UK
| | - Giorgio Caratti
- Oxford Centre for Diabetes, Endocrinology and Metabolism, NIHR Oxford Biomedical Research Centre, University of Oxford, Churchill Hospital, Oxford OX3 7LE, UK
| | - David W Ray
- Oxford Centre for Diabetes, Endocrinology and Metabolism, NIHR Oxford Biomedical Research Centre, University of Oxford, Churchill Hospital, Oxford OX3 7LE, UK
- NIHR Oxford Biomedical Research Centre, John Radcliffe Hospital, Oxford OX3 9DU, UK
- Oxford Kavli Centre for Nanoscience Discovery, University of Oxford, Oxford OX37LE, UK
| | - Jeremy W Tomlinson
- Oxford Centre for Diabetes, Endocrinology and Metabolism, NIHR Oxford Biomedical Research Centre, University of Oxford, Churchill Hospital, Oxford OX3 7LE, UK
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Li Z, Chen L, Sepulveda M, Wang P, Rasic M, Tullius SG, Perkins D, Alegre ML. Microbiota-dependent and -independent effects of obesity on transplant rejection and hyperglycemia. Am J Transplant 2023; 23:1526-1535. [PMID: 37356668 PMCID: PMC10543612 DOI: 10.1016/j.ajt.2023.06.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 06/11/2023] [Indexed: 06/27/2023]
Abstract
Obesity is associated with dysbiosis and a state of chronic inflammation that contributes to the pathogenesis of metabolic diseases, including diabetes. We have previously shown that obese mice develop glucose intolerance, increased alloreactivity, and accelerated transplant rejection. In the present study, we investigated the influence of the microbiota on diet-induced obesity (DIO)-associated transplant rejection and hyperglycemia. Antibiotic treatment prolonged graft survival and reduced fasting glycemia in high-fat diet (HFD)-fed specific-pathogen-free (SPF) mice, supporting a role for the microbiota in promoting accelerated graft rejection and hyperglycemia induced by DIO. Further supporting a microbiota-dependent effect, fecal microbiota transfer from DIO SPF mice into germ-free mice also accelerated graft rejection when compared with lean mice-fecal microbiota transfer. Notably, HFD could be also detrimental to the graft independently from microbiota, obesity, and hyperglycemia. Thus, whereas HFD-associated hyperglycemia was exclusively microbiota-dependent, HFD affected transplant outcomes via both microbiota-dependent and -independent mechanisms. Importantly, hyperglycemia in DIO SPF mice could be reduced by the addition of the gut commensal Alistipes onderdonkii, which alleviated both HFD-induced inflammation and glucose intolerance. Thus, microbial dysbiosis can be manipulated via antibiotics or select probiotics to counter some of the pathogenic effects of obesity in transplantation.
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Affiliation(s)
- Zhipeng Li
- Department of Medicine, University of Chicago, Chicago, Illinois, USA
| | - Luqiu Chen
- Department of Medicine, University of Chicago, Chicago, Illinois, USA
| | - Martin Sepulveda
- Department of Medicine, University of Chicago, Chicago, Illinois, USA
| | - Peter Wang
- Department of Medicine, University of Chicago, Chicago, Illinois, USA
| | - Mladen Rasic
- Department of Nephrology, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Stefan G Tullius
- Division of Transplant Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - David Perkins
- Department of Nephrology, University of Illinois at Chicago, Chicago, Illinois, USA
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Msalbi D, Jellali F, Elloumi-Mseddi J, Hakim B, Sahli E, Aifa S. Toxicity evaluation of synthetic glucocorticoids against breast cancer cell lines MDA-MB-231, MCF-7 and human embryonic kidney HEK293. Med Oncol 2023; 40:309. [PMID: 37773302 DOI: 10.1007/s12032-023-02189-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 09/07/2023] [Indexed: 10/01/2023]
Abstract
In this study, we conducted a comprehensive assessment of the cytotoxicity of three glucocorticoids, namely Hydrocortisone, Dexamethasone, and Methylprednisolone, using three different human cell lines: MDA-MB-231, MCF-7 (both adenocarcinoma cell lines), and HEK293 (kidney epithelial cell line). At lower concentrations exceeding 50 µM, we did not observe any significant toxic effects of these glucocorticoids. However, when exposed to higher concentrations, Hydrocortisone exhibited dose-dependent cytotoxic effects on all three cell lines, with calculated IC50 values of 12 ± 0.6 mM for HEK293, 2.11 ± 0.05 mM for MDA-MB-231, and 2.73 ± 0.128 mM for MCF-7 cells after 48 h of exposure. Notably, Hydrocortisone, at its respective IC50 concentrations, demonstrated an inhibitory effect on the proliferation of the cancer cell lines, as evidenced by a substantial reduction in BrdU absorbance in a dose-dependent manner, coupled with a markedly reduced rate of colony formation in treated cells. Furthermore, Hydrocortisone exhibited remarkable anti-migratory properties in MDA-MB-231 and MCF-7 cells, and it induced cell cycle arrest in the SubG1 phase in MDA-MB-231 cells. In addition to these effects, Hydrocortisone triggered apoptosis in both cancer cell types, leading to observable morphological changes. This apoptotic response was characterized by a significant increase in the activity of caspase-3, which was time-dependent. Additionally, Hydrocortisone downregulated the expression of anti-apoptotic Bcl-2 proteins. In summary, our findings underscore the safety of clinical doses in terms of cell toxicity meanwhile increased concentration were showing an anti-proliferative potential of Hydrocortisone, particularly against adenocarcinoma breast cancer cell lines.
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Affiliation(s)
- Dhouha Msalbi
- Laboratory of Molecular and Cellular Screening Processes, Centre of Biotechnology of Sfax, University of Sfax, Sidi Mansour Road Km 6, BP 1177, 3018, Sfax, Tunisia.
| | - Fatma Jellali
- Laboratory of Molecular and Cellular Screening Processes, Centre of Biotechnology of Sfax, University of Sfax, Sidi Mansour Road Km 6, BP 1177, 3018, Sfax, Tunisia
| | - Jihene Elloumi-Mseddi
- Laboratory of Molecular and Cellular Screening Processes, Centre of Biotechnology of Sfax, University of Sfax, Sidi Mansour Road Km 6, BP 1177, 3018, Sfax, Tunisia
| | - Bochra Hakim
- Laboratory of Molecular and Cellular Screening Processes, Centre of Biotechnology of Sfax, University of Sfax, Sidi Mansour Road Km 6, BP 1177, 3018, Sfax, Tunisia
| | - Emna Sahli
- Laboratory of Molecular and Cellular Screening Processes, Centre of Biotechnology of Sfax, University of Sfax, Sidi Mansour Road Km 6, BP 1177, 3018, Sfax, Tunisia
| | - Sami Aifa
- Laboratory of Molecular and Cellular Screening Processes, Centre of Biotechnology of Sfax, University of Sfax, Sidi Mansour Road Km 6, BP 1177, 3018, Sfax, Tunisia
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See KC. Impact of inhaled and intranasal corticosteroids on glucose metabolism and diabetes mellitus: A mini review. World J Diabetes 2023; 14:1202-1211. [PMID: 37664474 PMCID: PMC10473946 DOI: 10.4239/wjd.v14.i8.1202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Revised: 05/28/2023] [Accepted: 07/11/2023] [Indexed: 08/11/2023] Open
Abstract
Inhaled corticosteroids (ICS) and intranasal corticosteroids (INS) are the mainstays of treatment for chronic respiratory diseases like asthma, chronic obstructive pulmonary disease, and allergic rhinosinusitis. In addition, these localized forms of steroid therapy are generally considered to have fewer systemic side effects compared to long-term oral corticosteroids. However, concern and controversy remain over the impact of ICS and INS on the incidence and control of diabetes mellitus (DM). Given the widespread use of ICS and INS, even small individual effects on DM could lead to large consequences for the global popu-lation. Multiple large observational studies suggest that high dose ICS is associated with increased incident DM and worsened DM control, though the contribution of other risk factors is less certain. In addition, only two studies were done to investigate the association of INS and DM, with both studies demon-strating a short-term association of INS use with hyperglycemia. While more research evaluating the risk of ICS/INS for DM-related adverse events is needed, high doses of ICS/INS should be avoided when possible. The following strategies for ICS/INS dose minimization can be considered: Use of non-pharmacological measures (trigger avoidance, smoking cessation, vaccination to avoid infection), control of comorbid conditions, use of non-ICS-containing medications, inter-mittent rather than regular ICS dosing, and appropriate de-escalation of high ICS doses.
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Affiliation(s)
- Kay Choong See
- Department of Medicine, National University Hospital, Singapore 119228, Singapore
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9
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Heeley AM, Brodbelt DC, O'Neill DG, Church DB, Davison LJ. Assessment of glucocorticoid and antibiotic exposure as risk factors for diabetes mellitus in selected dog breeds attending UK primary-care clinics. Vet Rec 2023; 192:e2785. [PMID: 37004211 PMCID: PMC10952602 DOI: 10.1002/vetr.2785] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 02/06/2023] [Accepted: 02/22/2023] [Indexed: 04/03/2023]
Abstract
BACKGROUND Diabetes mellitus (DM) is an important endocrine disorder in dogs. This study explored prior exposure to glucocorticoids or antibiotic treatment as risk factors for developing DM in dogs attending primary-care VetCompass clinics in the UK. METHODS A breed frequency matched case-control study nested in a cohort of dogs (n = 480,469) aged 3 years or over was used to explore associations between glucocorticoid and antibiotic exposure and the odds of developing DM. RESULTS A total of 565 cases and 2179 controls were included. Dogs with DM had over four times the odds of exposure to glucocorticoids within 6 weeks prior to diagnosis (odds ratio [OR] 4.07, 95% confidence interval [CI] 2.41-6.89, p < 0.001) compared to controls within 6 weeks prior to a randomly selected quasi-date of diagnosis. Dogs that had only one unique documented antibiotic course had a decreased odds of developing DM (OR 0.65, 95% CI 0.46-0.91, p = 0.012) compared to dogs that had no documented courses of antibiotics. LIMITATIONS This study only included selected breeds, so the results may not be generalisable to all dog breeds. CONCLUSIONS Exposure to glucocorticoids is associated with a substantial increase in the risk of developing DM for the dog breeds included in this analysis.
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Affiliation(s)
- Angela M. Heeley
- Department of Pathobiology and Population SciencesRoyal Veterinary CollegeHatfieldUK
| | - Dave C. Brodbelt
- Department of Pathobiology and Population SciencesRoyal Veterinary CollegeHatfieldUK
| | - Dan G. O'Neill
- Department of Pathobiology and Population SciencesRoyal Veterinary CollegeHatfieldUK
| | - David B. Church
- Department of Clinical Science and ServicesRoyal Veterinary CollegeHatfieldUK
| | - Lucy J. Davison
- Department of Clinical Science and ServicesRoyal Veterinary CollegeHatfieldUK
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10
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Barker HL, Morrison D, Llano A, Sainsbury CAR, Jones GC. Practical Guide to Glucocorticoid Induced Hyperglycaemia and Diabetes. Diabetes Ther 2023; 14:937-945. [PMID: 36961675 PMCID: PMC10037401 DOI: 10.1007/s13300-023-01393-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 03/07/2023] [Indexed: 03/25/2023] Open
Abstract
Glucocorticoids, also known as steroids, are a class of anti-inflammatory drugs utilised widely in clinical practice for a variety of conditions. They are associated with a range of side effects including abnormalities of glucose metabolism. Multiple guidelines have been published to illustrate best management of glucocorticoid-induced hyperglycaemia and diabetes in a variety of settings. This article discusses current best clinical practice including diagnosis, investigations and ongoing management of glucocorticoid-induced dysglycaemia in both in- and outpatient settings.
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Affiliation(s)
- Hannah L. Barker
- Diabetes Department, Gartnavel General Hospital, Glasgow University, 1053 Great Western Road, Glasgow, G12 0YN UK
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11
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Guo YR, Liu XM, Wang GX. Exposure to proton pump inhibitors and risk of diabetes: A systematic review and meta-analysis. World J Diabetes 2023; 14:120-129. [PMID: 36926660 PMCID: PMC10011897 DOI: 10.4239/wjd.v14.i2.120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Revised: 12/20/2022] [Accepted: 01/19/2023] [Indexed: 02/14/2023] Open
Abstract
BACKGROUND Exposure to proton pump inhibitors (PPIs) has been reported to have a potential role in the development of diabetes.
AIM To determine the association between PPIs and diabetes.
METHODS This meta-analysis is registered on PROSPERO (CRD42022352704). In August 2022, eligible studies were identified through a comprehensive literature search. In this study, odds ratios were combined with 95% confidence intervals using a random-effects model. The source of heterogeneity was assessed using sensitivity analysis and subgroup analysis. The publication bias was evaluated using Egger’s test and Begg’s test.
RESULTS The meta-analysis included 9 studies with a total of 867185 participants. Results showed that the use of PPIs increased the risk of diabetes (odds ratio = 1.23, 95% confidence interval: 1.05-1.43, n = 9, I2 = 96.3%). Subgroup analysis showed that geographic location and study type had significant effects on the overall results. Both Egger’s and Begg’s tests showed no publication bias (P > 0.05). Sensitivity analysis also confirmed the stability of the results.
CONCLUSION The results of this study indicated that the use of PPIs was related to an increased risk of diabetes. However, more well-designed studies are needed to verify these results in the future.
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Affiliation(s)
- Yun-Ran Guo
- Department of Endocrinology and Metabolism, The First Hospital of Jilin University, Changchun 130000, Jilin Province, China
| | - Xin-Ming Liu
- Department of Endocrinology and Metabolism, The First Hospital of Jilin University, Changchun 130000, Jilin Province, China
| | - Gui-Xia Wang
- Department of Endocrinology and Metabolism, The First Hospital of Jilin University, Changchun 130000, Jilin Province, China
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12
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Zhu JL, Hong L, Yuan SQ, Xu XM, Wei JR, Yin HY. Association between glucocorticoid use and all-cause mortality in critically ill patients with heart failure: A cohort study based on the MIMIC-III database. Front Pharmacol 2023; 14:1118551. [PMID: 36713831 PMCID: PMC9877223 DOI: 10.3389/fphar.2023.1118551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 01/02/2023] [Indexed: 01/13/2023] Open
Abstract
Background: Heart failure (HF) is the terminal stage of various heart diseases. Conventional treatments have poor efficacy, and diuretic resistance can present. Previous studies have found that the use of glucocorticoids can enhance the diuretic effect of patients with heart failure and reduce heart failure symptoms. However, the relationship between glucocorticoid use and mortality in patients with heart failure in intensive care units is unclear. Objectives: The aim of this study was to determine the association between glucocorticoid use and all-cause mortality in critically ill patients with heart failure. Methods: The information on patients with heart failure in this study was extracted from the MIMIC-III (Medical Information Mart for Intensive Care-III) database. Patients in the glucocorticoid and non-glucocorticoid groups were matched using propensity scores. The Kaplan-Meier method was used to explore the difference in survival probability between the two groups. A Cox proportional-hazards regression model was used to analyze the hazard ratios (HRs) for the two patient groups. Subgroup analyses were performed with prespecified stratification variables to demonstrate the robustness of the results. Results: The study included 9,482 patients: 2,099 in the glucocorticoid group and 7,383 in the non-glucocorticoid group. There were 2,055 patients in each group after propensity-score matching. The results indicated that the non-glucocorticoid group was not significantly associated with reduced mortality in patients with heart failure during the 14-day follow-up period [HRs = .901, 95% confidence interval (CI) = .767-1.059]. During the follow-up periods of 15-30 and 15-90 days, the mortality risk was significantly lower in the non-glucocorticoid group than in the glucocorticoid group (HRs = .497 and 95% CI = .370-.668, and HRs = .400 and 95% CI = .310-.517, respectively). Subgroup analyses indicated no interaction among each stratification variable and glucocorticoid use. Conclusion: Glucocorticoid use was associated with an increased mortality risk in critically ill patients with heart failure.
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Affiliation(s)
- Jia-Liang Zhu
- Department of Intensive Care Unit, The First Affiliated Hospital of Jinan University, Guangzhou, Guangdong, China,Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Liang Hong
- Department of Intensive Care Unit, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Shi-Qi Yuan
- Department of Neurology, The First Affiliated Hospital of Jinan University, Guangzhou, Guangdong, China
| | - Xiao-Mei Xu
- Department of Intensive Care Unit, The First Affiliated Hospital of Jinan University, Guangzhou, Guangdong, China,Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Jian-Rui Wei
- Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, Guangdong, China,*Correspondence: Jian-Rui Wei, ; Hai-Yan Yin,
| | - Hai-Yan Yin
- Department of Intensive Care Unit, The First Affiliated Hospital of Jinan University, Guangzhou, Guangdong, China,*Correspondence: Jian-Rui Wei, ; Hai-Yan Yin,
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13
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Archontakis Barakakis P, Tran T, You JY, Hernandez Romero GJ, Gidwani V, Martinez FJ, Fortis S. High versus Medium Dose of Inhaled Corticosteroid in Chronic Obstructive Lung Disease: A Systematic Review and Meta-Analysis. Int J Chron Obstruct Pulmon Dis 2023; 18:469-482. [PMID: 37056683 PMCID: PMC10086393 DOI: 10.2147/copd.s401736] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 03/27/2023] [Indexed: 04/15/2023] Open
Abstract
Background Inhaled corticosteroids (ICSs) combined with bronchodilators have been identified to improve outcomes in COPD but also to be associated with certain adverse effects. Objective We performed a systematic review and meta-analysis to compile and summarize data on the efficacy and safety of dosing levels (high versus medium/low) of ICS alongside ancillary bronchodilators following PRISMA guidelines. Data Sources Medline and Embase were systematically searched until December 2021. Randomized, clinical trials (RCTs) that met predefined inclusion criteria were included. Data Extraction Risk ratios (RRs) with 95% confidence intervals (CI) were extracted. Any acute exacerbation of COPD (AECOPD) risk was chosen as the primary efficacy outcome, mortality rate as the primary safety outcome, moderate/severe AECOPD risk as the secondary efficacy outcome and pneumonia risk as the secondary safety outcome. Subgroup analyses of individual ICS agents, of patients with baseline moderate/severe/very severe COPD and of patients with recent COPD exacerbation history were also performed. A random-effects model was used. Results We included 13 RCTs in our study. No data on low doses were included in the analysis. High dose ICS was not associated with a statistically significant difference in any AECOPD risk (RR: 0.98, 95% CI: 0.91-1.05, I2: 41.3%), mortality rate (RR: 0.99, 95% CI: 0.75-1.32, I2: 0.0%), moderate/severe AECOPD risk (RR: 1.01, 95% CI: 0.96-1.06, I2: 0.0%) or pneumonia risk (RR: 1.07, 95% CI: 0.86 -1.33, I2: 9.3%) compared to medium dose ICS. The same trend was identified with the several subgroup analyses. Conclusion Our study collected RCTs investigating the optimal dosing level of ICS prescribed alongside ancillary bronchodilators to patients with COPD. We identified that the high ICS dose neither reduces AECOPD risk and mortality rates nor increases pneumonia risk relative to the medium dose.
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Affiliation(s)
- Paraschos Archontakis Barakakis
- Northeast Internal Medicine Associates, LaGrange, IN, USA
- Correspondence: Paraschos Archontakis Barakakis, Northeast Internal Medicine Associates, 4344 Love Grass Lane, Fort Wayne, LaGrange, IN, 46845, USA, Tel +1 929-422-4589, Email
| | - Thuonghien Tran
- Division of Pulmonary, Critical Care, and Occupational Medicine, Department of Internal Medicine, University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, IA, USA
| | - Jee Young You
- Department of Pulmonary and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
| | | | - Vipul Gidwani
- Northeast Internal Medicine Associates, LaGrange, IN, USA
| | - Fernando J Martinez
- Departments of Medicine and Genetic Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Spyridon Fortis
- Division of Pulmonary, Critical Care, and Occupational Medicine, Department of Internal Medicine, University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, IA, USA
- Veterans Rural Health Resource Center, VA Office of Rural Health, and Center for Access and Delivery Research and Evaluation (CADRE) at the Iowa City VA Healthcare System, Iowa City, IA, USA
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Tonietto RG, Bortolini GC, Figueiró GL, Raupp IS, Côcco MLC, Coser TBS, Lima LKM, Fighera TM. Clinical profile and severity predictors of coronavirus disease 19 infection in a reference center from southern Brazil: a cross-sectional study. REVISTA DA ASSOCIACAO MEDICA BRASILEIRA (1992) 2023; 69:e20221271. [PMID: 37075446 PMCID: PMC10176631 DOI: 10.1590/1806-9282.20221271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Accepted: 01/10/2023] [Indexed: 04/21/2023]
Abstract
OBJECTIVES The coronavirus disease pandemic has become a major global health crisis since 2019. Recent data show the association of diabetes, hypertension, and obesity with poor related outcomes in coronavirus disease infection. This descriptive study aimed to identify the clinical and laboratory parameters in patients with acute respiratory syndrome and confirmed severe acute respiratory syndrome coronavirus 2 infection. METHODS In this cross-sectional study, we analyzed data of 409 patients admitted to a referral hospital in Rio Grande do Sul, Brazil, with coronavirus disease infection confirmed by reverse transcription polymerase chain reaction. Clinical, laboratory, and imaging data were collected retrospectively from electronic medical records using a template with the variables of interest. RESULTS The average age was 64 years (52-73), and the body mass index was 27 kg/m² (22.1-31.2). Hypertension, diabetes, and obesity were observed in 58, 33, and 32% of the patients, respectively. Patients admitted to an intensive care unit were older [66 years (53-74) vs. 59 years (42.2-71.7)], with significantly higher impairment on chest computed tomography [75% (50-75) vs. 50% (25-60)] and received higher doses of corticosteroid therapy [39.4 mg (14.3-70.3) vs. 6 mg (6-14.7)]. Hematological parameters were lower in critically ill patients, with greater differences observed on the fifth day of hospitalization [hemoglobin 11.5 g/dL (9.5-13.1) vs. 12.8 g/dL (11.5-14.2), platelets 235,000 μL (143,000-357,000) vs. 270,000 μL (192,000-377,000), and lymphocytes 900 μL (555-1,500) vs. 1,629 μL (1,141-2,329)]. C-reactive protein levels and kidney function were also worse in intensive care unit patients. The mortality rate was significantly higher in the intensive care unit compared to the basic care unit (62.8 vs. 12.2%). CONCLUSION Our findings suggest that metabolic and cardiovascular comorbidities, as well as abnormal hematological parameters, are common findings among patients with severe respiratory syndrome related to coronavirus disease.
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Affiliation(s)
- Roberto Guidotti Tonietto
- Pontifícia Universidade Católica do Rio Grande do Sul, Hospital São Lucas, Pneumology Division - Porto Alegre (RS), Brazil
- Hospital Moinhos de Vento, Pneumology Division - Porto Alegre (RS), Brazil
| | | | | | - Igor Salvaro Raupp
- Universidade Luterana do Brasil, Hospital Universitário de Canoas - Canoas (RS), Brazil
| | | | | | | | - Tayane Muniz Fighera
- Universidade Federal do Rio Grande do Sul, Department of Internal Medicine - Porto Alegre (RS), Brazil
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15
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Patel NJ, Tozzo V, Higgins JM, Stone JH. The Effects of Daily Prednisone and Tocilizumab on Hemoglobin A 1c During the Treatment of Giant Cell Arteritis. Arthritis Rheumatol 2022; 75:586-594. [PMID: 36383175 DOI: 10.1002/art.42405] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 08/17/2022] [Accepted: 11/08/2022] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To study the longitudinal effects of both glucocorticoids and tocilizumab, an interleukin-6 receptor inhibitor, on hemoglobin A1c (HbA1c ) levels during glucocorticoid tapering. METHODS We analyzed patients with complete data from the Tocilizumab in Giant Cell Arteritis (GiACTA) trial to investigate the impact of both glycemic and nonglycemic factors on changes in HbA1c levels over the 52-week trial. Giant cell arteritis (GCA) patients were randomized to receive either tocilizumab or placebo in addition to glucocorticoids. We used a multivariable mixed-effects model to evaluate associations of HbA1c level with daily glucocorticoid dose, randomization to receive tocilizumab, and red blood cell count in patients with and those without diabetes mellitus at baseline, over 52 weeks. RESULTS In 209 patients, the median HbA1c level decreased by 0.50% (P < 0.01) in the group that received both tocilizumab and glucocorticoids (tocilizumab/glucocorticoid) and by 0.10% (P < 0.01) in the glucocorticoid-only group. Randomization to tocilizumab/glucocorticoid was associated with lower HbA1c (β = -0.209% in those without diabetes, P < 0.01; β = -0.290% in those with diabetes, P = 0.23). These changes had a sizable impact on glucose tolerance classification: 42.5% of patients in the tocilizumab/glucocorticoid group improved from prediabetes status to normal, compared to only 12.5% of patients treated with glucocorticoids alone. Daily glucocorticoid dose was associated with HbA1c level in patients with baseline diabetes (β = 0.018%/mg, P < 0.01) and those without baseline diabetes (β = 0.005%/mg, P < 0.01). CONCLUSION Tocilizumab treatment was associated with a substantial reduction in HbA1c level, independent of glucocorticoid exposure, which may be achieved through a combination of glycemic and nonglycemic effects.
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Affiliation(s)
- Naomi J Patel
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston
| | - Veronica Tozzo
- Department of Pathology and Center for Systems Biology, Massachusetts General Hospital, and Department of Systems Biology, Harvard Medical School, Boston, Massachusetts
| | - John M Higgins
- Department of Pathology and Center for Systems Biology, Massachusetts General Hospital, and Department of Systems Biology, Harvard Medical School, Boston, Massachusetts
| | - John H Stone
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston
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16
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Ambery P, Adamsson Eryd S, Jenkins-Jones S, Heywood B, Berni E, Brown MN, Astbury C, Hunt P, Currie CJ. The absolute risk of incident type 2 diabetes following exposure to systemic corticosteroids in selected steroid-related and phenotypic groups. Diabetes Obes Metab 2022; 24:2222-2231. [PMID: 35791627 DOI: 10.1111/dom.14808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 06/15/2022] [Accepted: 07/01/2022] [Indexed: 12/01/2022]
Abstract
AIMS Exposure to corticosteroids is known to increase the risk of developing type 2 diabetes. We estimated the risk of incident type 2 diabetes in selected patient groups exposed to systemic corticosteroids. MATERIALS AND METHODS In a retrospective, observational cohort study, using real-world data from UK primary care, patients were selected who had at least one episode of exposure to oral or intravenous corticosteroids for any indication. Corticosteroid-exposed patients were matched with non-exposed patients. Relative dosage was estimated as a weight-based, prednisolone-equivalent dose. Crude rates of progression to type 2 diabetes were determined for patient groups defined by relevant steroid-related and phenotypic characteristics present at corticosteroid exposure. RESULTS Overall, rates of incidence of type 2 diabetes were 12.5 and 6.7 events per thousand person-years' (pkpy) exposure, respectively, in those who received at least one dose of corticosteroids versus those never exposed. This represented a rate ratio of 1.85 (95% CI 1.74-1.97). The incidence of type 2 diabetes was found to be associated with several of the selected characteristics, both individually and multi-dimensionally. The highest rate of incident type 2 diabetes was observed in very severely obese men aged 46-55 years having had the longest corticosteroid exposure and highest corticosteroid dose (190 incident events pkpy exposure). CONCLUSIONS Corticosteroid exposure increased the risk of incident type 2 diabetes, and there was evidence of both a dose-response and a duration response. The impact of corticosteroid exposure upon the rate of incident type 2 diabetes appeared, however, to involve a complex, multi-dimensional interaction between the selected characteristics, some of which might be impacted by reverse causality.
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Affiliation(s)
- Philip Ambery
- Late-stage Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | | | | | - Ben Heywood
- Global Epidemiology, Pharmatelligence, Cardiff, UK
| | - Ellen Berni
- Global Epidemiology, Pharmatelligence, Cardiff, UK
| | - Mary N Brown
- Research and Early Development, Respiratory & Immunology, BioPharmaceuticals R&D, AstraZeneca, Boston, Massachusetts, USA
| | - Carol Astbury
- Research and Early Development, Respiratory & Immunology, BioPharmaceuticals R&D, AstraZeneca, Cambridge, UK
| | - Phillip Hunt
- BioPharmaceuticals Medical, CVRM Evidence, AstraZeneca, Gaithersburg, Maryland, USA
| | - Craig J Currie
- Global Epidemiology, Pharmatelligence, Cardiff, UK
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
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17
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Hickey SL, McKim A, Mancuso CA, Krishnan A. A network-based approach for isolating the chronic inflammation gene signatures underlying complex diseases towards finding new treatment opportunities. Front Pharmacol 2022; 13:995459. [PMCID: PMC9597699 DOI: 10.3389/fphar.2022.995459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 08/19/2022] [Indexed: 11/13/2022] Open
Abstract
Complex diseases are associated with a wide range of cellular, physiological, and clinical phenotypes. To advance our understanding of disease mechanisms and our ability to treat these diseases, it is critical to delineate the molecular basis and therapeutic avenues of specific disease phenotypes, especially those that are associated with multiple diseases. Inflammatory processes constitute one such prominent phenotype, being involved in a wide range of health problems including ischemic heart disease, stroke, cancer, diabetes mellitus, chronic kidney disease, non-alcoholic fatty liver disease, and autoimmune and neurodegenerative conditions. While hundreds of genes might play a role in the etiology of each of these diseases, isolating the genes involved in the specific phenotype (e.g., inflammation “component”) could help us understand the genes and pathways underlying this phenotype across diseases and predict potential drugs to target the phenotype. Here, we present a computational approach that integrates gene interaction networks, disease-/trait-gene associations, and drug-target information to accomplish this goal. We apply this approach to isolate gene signatures of complex diseases that correspond to chronic inflammation and use SAveRUNNER to prioritize drugs to reveal new therapeutic opportunities.
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Affiliation(s)
- Stephanie L. Hickey
- Department of Biochemistry and Molecular Biology, Michigan State University, East Lansing, MI, United States
| | - Alexander McKim
- Department of Computational Mathematics, Science and Engineering, Michigan State University, East Lansing, MI, United States
- Genetics and Genome Sciences Program, Michigan State University, East Lansing, MI, United States
| | - Christopher A. Mancuso
- Department of Computational Mathematics, Science and Engineering, Michigan State University, East Lansing, MI, United States
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado-Denver Anschutz Medical Campus, Aurora, CO, United States
| | - Arjun Krishnan
- Department of Biochemistry and Molecular Biology, Michigan State University, East Lansing, MI, United States
- Department of Computational Mathematics, Science and Engineering, Michigan State University, East Lansing, MI, United States
- Department of Biomedical Informatics, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
- *Correspondence: Arjun Krishnan,
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18
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Grover KM, Sripathi N. Prevention of Adverse Outcomes and Treatment Side Effects in Patients with Neuromuscular Disorders. Semin Neurol 2022; 42:594-610. [PMID: 36400111 DOI: 10.1055/s-0042-1758779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
In this article, we review prevention of serious adverse clinical outcomes and treatment side effects in patients with neuromuscular disorders including myopathies and myasthenia gravis. While neither of these entities is preventable, their course can often be modified, and severe sequelae may be prevented, with the identification of risk factors and proactive attention toward treatment planning.
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Affiliation(s)
- Kavita M Grover
- Department of Neurology, Henry Ford Medical Group, Wayne State University, Detroit, Michigan
| | - Naganand Sripathi
- Department of Neurology, Henry Ford Medical Group, Wayne State University, Detroit, Michigan
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19
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Li JX, Cummins CL. Fresh insights into glucocorticoid-induced diabetes mellitus and new therapeutic directions. Nat Rev Endocrinol 2022; 18:540-557. [PMID: 35585199 PMCID: PMC9116713 DOI: 10.1038/s41574-022-00683-6] [Citation(s) in RCA: 55] [Impact Index Per Article: 27.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/21/2022] [Indexed: 02/08/2023]
Abstract
Glucocorticoid hormones were discovered to have use as potent anti-inflammatory and immunosuppressive therapeutics in the 1940s and their continued use and development have successfully revolutionized the management of acute and chronic inflammatory diseases. However, long-term use of glucocorticoids is severely hampered by undesirable metabolic complications, including the development of type 2 diabetes mellitus. These effects occur due to glucocorticoid receptor activation within multiple tissues, which results in inter-organ crosstalk that increases hepatic glucose production and inhibits peripheral glucose uptake. Despite the high prevalence of glucocorticoid-induced hyperglycaemia associated with their routine clinical use, treatment protocols for optimal management of the metabolic adverse effects are lacking or underutilized. The type, dose and potency of the glucocorticoid administered dictates the choice of hypoglycaemic intervention (non-insulin or insulin therapy) that should be provided to patients. The longstanding quest to identify dissociated glucocorticoid receptor agonists to separate the hyperglycaemic complications of glucocorticoids from their therapeutically beneficial anti-inflammatory effects is ongoing, with selective glucocorticoid receptor modulators in clinical testing. Promising areas of preclinical research include new mechanisms to disrupt glucocorticoid signalling in a tissue-selective manner and the identification of novel targets that can selectively dissociate the effects of glucocorticoids. These research arms share the ultimate goal of achieving the anti-inflammatory actions of glucocorticoids without the metabolic consequences.
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Affiliation(s)
- Jia-Xu Li
- Department of Pharmaceutical Sciences, Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
| | - Carolyn L Cummins
- Department of Pharmaceutical Sciences, Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada.
- Banting and Best Diabetes Centre, University of Toronto, Toronto, ON, Canada.
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20
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Shah P, Kalra S, Yadav Y, Deka N, Lathia T, Jacob JJ, Kota SK, Bhattacharya S, Gadve SS, Subramanium KAV, George J, Iyer V, Chandratreya S, Aggrawal PK, Singh SK, Joshi A, Selvan C, Priya G, Dhingra A, Das S. Management of Glucocorticoid-Induced Hyperglycemia. Diabetes Metab Syndr Obes 2022; 15:1577-1588. [PMID: 35637859 PMCID: PMC9142341 DOI: 10.2147/dmso.s330253] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 02/09/2022] [Indexed: 01/25/2023] Open
Abstract
Glucocorticoids are potent immunosuppressive and anti-inflammatory drugs used for various systemic and localized conditions. The use of glucocorticoids needs to be weighed against their adverse effect of aggravating hyperglycemia in persons with diabetes mellitus, unmask undiagnosed diabetes mellitus, or precipitate glucocorticoid-induced diabetes mellitus appearance. Hyperglycemia is associated with poor clinical outcomes, including infection, disability after hospital discharge, prolonged hospital stay, and death. Furthermore, clear guidelines for managing glucocorticoid-induced hyperglycemia are lacking. Therefore, this consensus document aims to develop guidance on the management of glucocorticoid-induced hyperglycemia. Twenty expert endocrinologists, in a virtual meeting, discussed the evidence and practical experience of real-life management of glucocorticoid-induced hyperglycemia. The expert group concluded that we should be proactive in terms of diagnosis, management, and post-steroid care. Since every patient has different severity of underlying disease, clinical stratification would help understand patient profiles and determine the treatment course. Patients at home with pre-existing diabetes who are already on oral or injectable therapy can continue the same as long as they are clinically stable and eating adequately. However, depending on the degree of hyperglycemia, modification of doses may be required. Initiating basal bolus with correction regimen is recommended for patients in non-intensive care unit settings. For patients in intensive care unit, variable rate intravenous insulin infusion could be temporarily used, but under supervision of diabetes inpatient team, and patients can be transitioned to subcutaneous insulin once stable baseline assessment and continual evaluation are crucial for day-to-day decisions concerning insulin doses. Glycemic variability should be carefully monitored, and interventions to treat patients should also aim at achieving and maintaining euglycemia. Rational use of glucose-lowering drugs is recommended and treatment regimen should ensure maximum safety for both patient and provider. Glucovigilance is required as the steroids taper during transition, and insulin dosage should be reduced subsequently. Increased clinical and economic burden resulting from corticosteroid-related adverse events highlights the need for effective management. Therefore, these recommendations would help successfully manage GC-induced hyperglycemia and judiciously allocate resources.
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Affiliation(s)
- Parag Shah
- Department of Endocrinology, Gujarat Endocrine Centre, Ahmedabad, Gujarat, India
| | - Sanjay Kalra
- Department of Endocrinology, Bharti Hospital & B.R.I.D.E, Karnal, Haryana, India
- Correspondence: Sanjay Kalra, Kunjpura Road, Model Town, Near State Bank of India, Sector 12, Karnal, Haryana, 132001, India, Tel +9215848555, Email
| | - Yogesh Yadav
- Department of Endocrinology, MAX Super Specialty Hospital, Dehradun, Uttarakhand, India
| | - Nilakshi Deka
- Department of Endocrinology, Apollo Hospital & Dispur Polyclinic and Nursing Home, Guwahati, West Bengal, India
| | - Tejal Lathia
- Department of Endocrinology, Apollo Hospital, Mumbai, Maharashtra, India
| | | | - Sunil Kumar Kota
- Department of Endocrinology, Diabetes and Endocrine Clinic, Berhampur, Orissa, India
| | - Saptrishi Bhattacharya
- Department of Endocrinology, OeHealth Diabates & Endocrinology Centre, Delhi, Delhi, India
| | - Sharvil S Gadve
- Department of Endocrinology, Excel Endocrine Centre, Kolhapur, Maharashtra, India
| | - K A V Subramanium
- Department of Endocrinology, Visakha Diabates & Endocrine Centre, Vishakhapatnam, Andhra Pradesh, India
| | - Joe George
- Department of Endocrinology, Endodiab Clinic, Calicut, Kerala, India
| | - Vageesh Iyer
- Department of Endocrinology, St.John’s Medical College & Hospital, Bangalore, Karnataka, India
| | - Sujit Chandratreya
- Department of Endocrinology, Endocare Clinic, Nashik, Maharashtra, India
| | - Pankaj Kumar Aggrawal
- Department of Endocrinology, Hormone Care & Research Centre, Ghaziabad, Uttar Pradesh, India
| | | | - Ameya Joshi
- Department of Endocrinology, Endocrine and Diabetes Clinic, Mumbai, Maharashtra, India
| | - Chitra Selvan
- Department of Endocrinology, Ramaiah Memorial Hospital, Bangalore, Karnataka, India
| | - Gagan Priya
- Department of Endocrinology, IVY Hospital, Chandigarh, Punjab, India
| | - Atul Dhingra
- Department of Endocrinology, Bansal Hospital, Sri Ganganagar, Rajasthan, India
| | - Sambit Das
- Department of Endocrinology, Endeavour Clinic, Bhubaneshwar, Orissa, India
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Bert A, Gilbert T, Cottin V, Mercier J, Gerfaud-Valentin M, Durieu I, Hot A, Hicks J, Varron L, Seve P, Jamilloux Y. Sarcoidosis diagnosed in the elderly: a case-control study. QJM 2021; 114:238-245. [PMID: 32569362 DOI: 10.1093/qjmed/hcaa171] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 04/18/2020] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Studies on sarcoidosis in elderly patients are scarce and none have specifically evaluated patients aged ≥75 at onset. AIM We aimed to analyse the characteristics of patients with sarcoidosis diagnosed after 75 and to compare them with those of younger patients. DESIGN Multicenter case-control study comparing elderly-onset sarcoidosis (EOS) with young-onset sarcoidosis (YOS) seen at Lyon University Hospitals between 2006 and 2018. METHODS Using our institutional database, we included 34 patients in the EOS group and compared them with 102 controls from the YOS group in a 1:3 ratio. Demographic characteristics, medical history, clinical presentation, laboratory and imaging findings, sites of biopsies, histological analyses, treatments and outcomes were recorded using a comprehensive questionnaire. RESULTS There were more Caucasians in the EOS group (94.1% vs. 59.8%; P < 0.001), who had significantly more comorbidities (mean, 3.1 ± 2 vs. 1.1 ± 1.6; P < 0.001). In the EOS group, there was less pulmonary involvement (26.5% vs. 49%; P = 0.022), less lymphadenopathy (2.9% vs. 16.7%; P = 0.041), no erythema nodosum (0% vs. 12.8%; P = 0.029) and no arthralgia (0% vs. 25.5%; P = 0.001). Conversely, uveitis was more common in the EOS group (55.9% vs. 20.6%; P < 0.001). Pathological confirmation was obtained significantly less frequently in the EOS group (67.7% vs. 85.3%; P = 0.023). Corticosteroid-related side effects were significantly more common in the EOS group (100% vs. 75.9%; P = 0.030). CONCLUSION Epidemiology and clinical presentation of EOS differs from YOS, including more comorbidities and more uveitis. Elderly patients are more prone to corticosteroid side effects.
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Affiliation(s)
- A Bert
- Department of Internal Medicine, University Hospital Lyon Croix-Rousse, Claude Bernard University Lyon 1, 103 Grande Rue de la Croix-Rousse, 69004 Lyon, France
| | - T Gilbert
- Short Stay Geriatric Unit, Lyon Sud University Hospital, University Claude Bernard University Lyon 1, 165 Chemin du Grand Revoyet, 69310 Pierre-Bénite, France
| | - V Cottin
- National Reference Center for Rare Pulmonary Diseases, Louis Pradel University Hospital, University Claude Bernard University Lyon 1, 59 Boulevard Pinel, 69500 Bron, France
| | - J Mercier
- Department of Internal Medicine, University Hospital Lyon Croix-Rousse, Claude Bernard University Lyon 1, 103 Grande Rue de la Croix-Rousse, 69004 Lyon, France
| | - M Gerfaud-Valentin
- Department of Internal Medicine, University Hospital Lyon Croix-Rousse, Claude Bernard University Lyon 1, 103 Grande Rue de la Croix-Rousse, 69004 Lyon, France
| | - I Durieu
- Department of Internal Medicine, Lyon Sud University Hospital, University Claude Bernard University Lyon 1, 165 Chemin du Grand Revoyet, 69310 Pierre-Bénite, France
| | - A Hot
- Department of Internal Medicine, Edouard Herriot University Hospital, University Claude Bernard University Lyon 1, 5 Place d'Arsonval, 69003 Lyon, France
| | - J Hicks
- Faculty of Medical Sciences, Newcastle University, Framlington Place, Newcastle upon Tyne NE2 4HH, UK
| | - L Varron
- Department of Internal Medicine, Montélimar Hospital, Quartier Beausseret, Route de Sauzet, 26200 Montélimar, France
| | - P Seve
- Department of Internal Medicine, University Hospital Lyon Croix-Rousse, Claude Bernard University Lyon 1, 103 Grande Rue de la Croix-Rousse, 69004 Lyon, France
| | - Y Jamilloux
- Department of Internal Medicine, University Hospital Lyon Croix-Rousse, Claude Bernard University Lyon 1, 103 Grande Rue de la Croix-Rousse, 69004 Lyon, France
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22
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Benmelouka AY, Abdelaal A, Mohamed ASE, Shamseldin LS, Zaki MM, Elsaeidy KS, Abdelmageed Mahmoud M, El-Qushayri AE, Ghozy S, Shariful Islam SM. Association between sarcoidosis and diabetes mellitus: a systematic review and meta-analysis. Expert Rev Respir Med 2021; 15:1589-1595. [PMID: 34018900 DOI: 10.1080/17476348.2021.1932471] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Background: Sarcoidosis is multisystem inflammatory granulomatosis that can potentially affect any organ of the human body. We aimed to estimate the prevalence of diabetes mellitus (DM) in sarcoidosis patients and determine the association between sarcoidosis and DM.Method: All relevant articles reporting the prevalence of DM in sarcoidosis published until September 19th, 2020, were retrieved from ten electronic databases. We used the random effect model to perform the meta-analysis.Results: After screening 2,122 records, we included 19 studies (n = 18,686,162). The prevalence of DM in sarcoidosis patients was 12.7% (95% CI 10-16.1). The prevalence was highest in North America with 21.3% (13.5-31.8), followed by Europe 10.4 (7.9-13.7) and Asia 10% (1.8-39.7). Sarcoidosis patients had higher rates of DM compared to controls (OR 1.75; 95% CI 1.49-2.05). Sensitivity analysis, after removing the largest weighted study, did not reveal any effect on the significance of the results (OR 1.73; 95% CI 1.33-2.25).Conclusion: The prevalence of DM in sarcoidosis is considerably high, with increased odds of DM in sarcoidosis compared to healthy controls. Further research with a wide range of confounders is required to confirm the association of sarcoidosis with DM.
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Affiliation(s)
- Amira Yasmine Benmelouka
- Faculty of Medicine, University of Algiers, Algiers, Algeria.,Global Medical Research Initiative, Egypt
| | | | | | - Laila Salah Shamseldin
- Global Medical Research Initiative, Egypt.,Faculty of Medicine, Zagazig University, Zagazig, El-Sharkia, Egypt
| | - Mahmoud Mohamed Zaki
- Global Medical Research Initiative, Egypt.,Faculty of Medicine, Zagazig University, Zagazig, El-Sharkia, Egypt
| | - Khaled Saad Elsaeidy
- Global Medical Research Initiative, Egypt.,Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | | | | | - Sherief Ghozy
- Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Sheikh Mohammed Shariful Islam
- Institute for Physical Activity and Nutrition (IPAN), School of Exercise and Nutrition Sciences, Deakin University, Melbourne, Australia
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Horton DB, Xie F, Chen L, Mannion ML, Curtis JR, Strom BL, Beukelman T. Oral Glucocorticoids and Incident Treatment of Diabetes Mellitus, Hypertension, and Venous Thromboembolism in Children. Am J Epidemiol 2021; 190:403-412. [PMID: 32902632 DOI: 10.1093/aje/kwaa197] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Revised: 09/02/2020] [Accepted: 09/04/2020] [Indexed: 12/23/2022] Open
Abstract
Rates of incident treatment were quantified in this study for diabetes mellitus, hypertension, and venous thromboembolism (VTE) associated with oral glucocorticoid exposure in children aged 1-18 years. The retrospective cohort included more than 930,000 children diagnosed with autoimmune diseases (namely, inflammatory bowel disease, juvenile idiopathic arthritis, or psoriasis) or a nonimmune comparator condition (attention-deficit/hyperactivity disorder) identified using US Medicaid claims (2000-2010). Associations of glucocorticoid dose per age- and sex-imputed weight with incident treated diabetes, hypertension, and VTE were estimated using Cox regression models. Crude rates were lowest for VTE (unexposed: 0.5/million person-days (95% confidence interval (CI): 0.4, 0.6); currently exposed: 15.6/million person-days (95% CI: 11.8, 20.1)) and highest for hypertension (unexposed: 6.7/million person-days (95% CI: 6.5, 7.0); currently exposed: 74.4/million person-days (95% CI: 65.7, 83.9)). Absolute rates for all outcomes were higher in unexposed and exposed children with autoimmune diseases compared with those with attention-deficit/hyperactivity disorder. Strong dose-dependent relationships were found between current glucocorticoid exposure and all outcomes (adjusted hazard ratios for high-dose glucocorticoids: for diabetes mellitus, 5.93 (95% CI: 3.94, 8.91); for hypertension, 19.13 (95% CI: 15.43, 23.73); for VTE, 16.16 (95% CI: 8.94, 29.22)). These results suggest strong relative risks, but low absolute risks, of newly treated VTE, diabetes, and especially hypertension in children taking high-dose oral glucocorticoids.
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McGraw M, White HD, Zolfaghari K, Hochhalter A, Arroliga A, Boethel C. Corticosteroid Dosing and Glucose Levels in COPD Patients Are Not Associated with Increased Readmissions. CHRONIC OBSTRUCTIVE PULMONARY DISEASES-JOURNAL OF THE COPD FOUNDATION 2021; 8. [PMID: 33238088 DOI: 10.15326/jcopdf.2020.0172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Introduction Hospital admissions and readmissions for chronic obstructive pulmonary disease (COPD) exacerbations are associated with increased mortality and higher cost. The management of exacerbations with a shortened course of systemic corticosteroids has similar efficacy as compared to longer steroid courses, but actual overall steroid dose given is still variable. The outcomes associated with steroid side effects, such as hyperglycemia, need further evaluation. We hypothesized that the use of higher doses of corticosteroids, and the subsequent hyperglycemia, contributes to readmission. Methods This is a retrospective study at a tertiary care referral center in central Texas between February 2014 and July 2016. Daily corticosteroid dose, blood glucose levels, and readmission rates at 30 and 31-90 days were recorded. Sample characteristics are described using descriptive statistics. A chi-square test or student's t-test were used to test for associations in bivariate comparisons. Multivariable logistic regression assessed the association between readmission rate and demographic and clinical characteristics. Results There were 1120 patients admitted for COPD exacerbation between February 2014 and July 2016. A total of 57% were female, mean age was 69 years (standard deviation [SD] 12), and average body mass index (BMI) was 29.4 (SD 9.8). Of the total, 349 (31%) had diabetes prior to admission. The 30-day readmission rate was 16%, and the readmission rate from 31-90 days was 14%. The average prednisone equivalent dose per day during hospitalization was 86 mg (SD 52). A multivariable logistic regression model did not show any significant association between readmission and average daily glucose, high maximum glucose (>180 mg/dL on any reading), or prednisone equivalent administered per day. Conclusion Corticosteroid dose and hyperglycemia were not associated with an increased 30-day or 31-90-day readmission rate after COPD exacerbation discharge. In addition, using higher doses of corticosteroids instead of standard-of-care (prednisone 40 mg per day for a 5-day period) did not appear to affect the readmission rate in this cohort.
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Affiliation(s)
- Meghan McGraw
- Division of Pulmonary, Critical Care and Sleep Medicine, Baylor Scott and White Health, Temple, Texas, United States
| | - Heath D White
- Division of Pulmonary, Critical Care and Sleep Medicine, Baylor Scott and White Health, Temple, Texas, United States
| | - Kiumars Zolfaghari
- Division of Pulmonary, Critical Care and Sleep Medicine, Baylor Scott and White Health, Temple, Texas, United States
| | - Angela Hochhalter
- Division of Pulmonary, Critical Care and Sleep Medicine, Baylor Scott and White Health, Temple, Texas, United States
| | - Alejandro Arroliga
- Division of Pulmonary, Critical Care and Sleep Medicine, Baylor Scott and White Health, Temple, Texas, United States
| | - Carl Boethel
- Division of Pulmonary, Critical Care and Sleep Medicine, Baylor Scott and White Health, Temple, Texas, United States
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Delfs N, Struja T, Gafner S, Muri T, Baechli C, Schuetz P, Mueller B, Blum CA. Outcomes of Hospitalized Patients with Glucocorticoid-Induced Hyperglycemia-A Retrospective Analysis. J Clin Med 2020; 9:jcm9124079. [PMID: 33348743 PMCID: PMC7765857 DOI: 10.3390/jcm9124079] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 11/30/2020] [Accepted: 12/09/2020] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Glucocorticoid (GC)-induced hyperglycemia is a frequent side effect in hospitalized patients. Guidelines recommend treat-to-target treatment between 6-10 mmol/L (108-180 mg/dL) with insulin, but data on outcome is scarce. We investigated the 30-day outcome in hospitalized patients receiving GCs. METHODS All patient records of hospitalized patients between January 2014 and April 2018 were screened for GC administration and consecutive hyperglycemia. The primary combined endpoint consisted of death, cardiovascular events, and infections until 30 days after admission. Hypoglycemia was a secondary outcome. RESULTS Of the 2424 hospitalized patients (9.6% of all hospitalized patients) who received systemic GCs and met inclusion criteria, the overall incidence for GC-induced hyperglycemia was 812 (33.5%), and 89 (3.7%) had at least one documented hypoglycemia during their hospital stay. Compared to patients with normoglycemia, GC-induced hyperglycemia had an adjusted-odds ratio of 1.68 (95% CI 1.25-2.26) for the combined primary endpoint. Hypoglycemia even had an odds ratio of 1.95 (95% CI 1.2-3.17). CONCLUSIONS Mortality, cardiovascular events, and rate of infections were markedly higher in patients with GC-induced hyperglycemia as compared to patients with normoglycemia. Importantly, hypoglycemia was associated with a doubled risk for adverse outcome. Future studies should evaluate whether optimized glucose control by minimizing the risk for hypoglycemia has a beneficial effect on clinical outcomes in patients with GC-induced hyperglycemia.
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Affiliation(s)
- Neele Delfs
- Departments of General Internal and Emergency Medicine, Medical University Clinic, Kantonsspital Aarau, Tellstrasse 25, Haus 7, 5001 Aarau, Switzerland; (N.D.); (T.S.); (S.G.); (T.M.); (B.M.)
- Department of Endocrinology and Diabetology, Medical University Clinic, Kantonsspital Aarau, Tellstrasse 25, Haus 7, 5001 Aarau, Switzerland; (C.B.); (P.S.)
| | - Tristan Struja
- Departments of General Internal and Emergency Medicine, Medical University Clinic, Kantonsspital Aarau, Tellstrasse 25, Haus 7, 5001 Aarau, Switzerland; (N.D.); (T.S.); (S.G.); (T.M.); (B.M.)
- Department of Endocrinology and Diabetology, Medical University Clinic, Kantonsspital Aarau, Tellstrasse 25, Haus 7, 5001 Aarau, Switzerland; (C.B.); (P.S.)
| | - Sandra Gafner
- Departments of General Internal and Emergency Medicine, Medical University Clinic, Kantonsspital Aarau, Tellstrasse 25, Haus 7, 5001 Aarau, Switzerland; (N.D.); (T.S.); (S.G.); (T.M.); (B.M.)
- Department of Endocrinology and Diabetology, Medical University Clinic, Kantonsspital Aarau, Tellstrasse 25, Haus 7, 5001 Aarau, Switzerland; (C.B.); (P.S.)
| | - Thaddaeus Muri
- Departments of General Internal and Emergency Medicine, Medical University Clinic, Kantonsspital Aarau, Tellstrasse 25, Haus 7, 5001 Aarau, Switzerland; (N.D.); (T.S.); (S.G.); (T.M.); (B.M.)
- Department of Endocrinology and Diabetology, Medical University Clinic, Kantonsspital Aarau, Tellstrasse 25, Haus 7, 5001 Aarau, Switzerland; (C.B.); (P.S.)
| | - Ciril Baechli
- Department of Endocrinology and Diabetology, Medical University Clinic, Kantonsspital Aarau, Tellstrasse 25, Haus 7, 5001 Aarau, Switzerland; (C.B.); (P.S.)
| | - Philipp Schuetz
- Department of Endocrinology and Diabetology, Medical University Clinic, Kantonsspital Aarau, Tellstrasse 25, Haus 7, 5001 Aarau, Switzerland; (C.B.); (P.S.)
| | - Beat Mueller
- Departments of General Internal and Emergency Medicine, Medical University Clinic, Kantonsspital Aarau, Tellstrasse 25, Haus 7, 5001 Aarau, Switzerland; (N.D.); (T.S.); (S.G.); (T.M.); (B.M.)
- Department of Endocrinology and Diabetology, Medical University Clinic, Kantonsspital Aarau, Tellstrasse 25, Haus 7, 5001 Aarau, Switzerland; (C.B.); (P.S.)
| | - Claudine Angela Blum
- Departments of General Internal and Emergency Medicine, Medical University Clinic, Kantonsspital Aarau, Tellstrasse 25, Haus 7, 5001 Aarau, Switzerland; (N.D.); (T.S.); (S.G.); (T.M.); (B.M.)
- Department of Endocrinology and Diabetology, Medical University Clinic, Kantonsspital Aarau, Tellstrasse 25, Haus 7, 5001 Aarau, Switzerland; (C.B.); (P.S.)
- Correspondence: ; Tel.: +41-62-838-6825
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Metsälä J, Lundqvist A, Virta LJ, Kaila M, Gissler M, Virtanen SM, Nevalainen J. Use of Antiasthmatic Drugs and the Risk of Type 1 Diabetes in Children: A Nationwide Case-Cohort Study. Am J Epidemiol 2020; 189:779-787. [PMID: 31971234 DOI: 10.1093/aje/kwaa002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 01/06/2020] [Indexed: 12/15/2022] Open
Abstract
Asthma has been reported to be associated with an increased risk of type 1 diabetes mellitus in childhood, but the reasons are unclear. We examined whether the use of antiasthmatic drugs was associated with the development of type 1 diabetes in childhood in a nationwide, register-based case-cohort study. We identified all children who were born January 1, 1995, through December 31, 2008, in Finland and diagnosed with type 1 diabetes by 2010 (n = 3,342). A 10% random sample from each birth-year cohort was selected as a reference cohort (n = 80,909). Information on all dispensed antiasthmatic drugs (Anatomical Therapeutic Chemical classification system code R03) during 1995-2009 was obtained, and associations between the use of antiasthmatic drugs and the development of type 1 diabetes were investigated using time-dependent and time-sequential Cox regression models. Dispensed inhaled corticosteroids and inhaled β-agonists were associated with an increased risk of type 1 diabetes after adjusting for other antiasthmatic drugs, asthma, sex, and birth decade (hazard ratio = 1.29, 95% confidence interval: 1.09, 1.52, and hazard ratio = 1.22, 95% confidence interval: 1.07, 1.41, respectively). These findings suggest that children using inhaled corticosteroids or inhaled β-agonists might be at increased risk of type 1 diabetes.
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Affiliation(s)
- Johanna Metsälä
- Department of Public Health Solutions, Finnish Institute for Health and Welfare, Helsinki, Finland
| | - Annamari Lundqvist
- Department of Public Health Solutions, Finnish Institute for Health and Welfare, Helsinki, Finland
| | - Lauri J Virta
- Research Department, Social Insurance Institution, Turku, Finland
| | - Minna Kaila
- Public Health Medicine, Faculty of Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Mika Gissler
- Information Services Department, Finnish Institute for Health and Welfare, Helsinki, Finland
- Department of Neurobiology, Care Sciences and Society, Karolinska Institute, Stockholm, Sweden
| | - Suvi M Virtanen
- Unit of Health Sciences, Faculty of Social Sciences, Tampere University, Tampere, Finland
- Science Centre, Tampere University Hospital, Tampere, Finland
- Tampere Center for Child Health Research, Tampere University and Tampere University Hospital, Finland
- Department of Public Health Solutions, Finnish Institute for Health and Welfare, Helsinki, Finland
| | - Jaakko Nevalainen
- Unit of Health Sciences, Faculty of Social Sciences, Tampere University, Tampere, Finland
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Implementation of a Weight-Based Protocol for the Management of Steroid-Induced Hyperglycemia. Am J Ther 2020; 27:e392-e399. [PMID: 32628394 DOI: 10.1097/mjt.0000000000000998] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Hyperglycemia is a recognized complication of supraphysiological steroid dosing. There are no consensus guidelines on optimal treatment of steroid-induced hyperglycemia. We assessed the safety of a weight-based insulin protocol for persons treated with supraphysiological doses of steroids to examine the efficacy of using this protocol in patients with diabetes treated with prednisone or methylprednisolone. AREAS OF UNCERTAINTY There is uncertainty about the optimal dosing of insulin to manage steroid-induced hyperglycemia; thus, a weight-based protocol was created with the goal of reaching euglycemia faster than current practice in persons with diabetes. Variables such as steroid dosing, baseline glycemic control, and duration of steroid use further complicated the ability to manage these patients. INNOVATIONS The interdisciplinary team of diabetes providers and pharmacists worked together to devise a protocol to manage steroid-induced hyperglycemia with the goal of reducing hyperglycemia while avoiding hypoglycemia, as well as to allow for less reliance on endocrine consultation. The protocol used weight, insulin naivety, renal function, blood glucose measurements, and steroid dosing to determine the insulin dose. There was some evidence to suggest the proportion of blood glucose levels more than 200 mg/dL was lower after protocol initiation compared with before protocol initiation (P = 0.053). Several factors decreased the rate of successful outcomes, including minimal primary team participation, accurate completion of calculations based on the protocol, and initiation of the protocol after several days of hyperglycemia.
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Wu J, Mackie SL, Pujades-Rodriguez M. Glucocorticoid dose-dependent risk of type 2 diabetes in six immune-mediated inflammatory diseases: a population-based cohort analysis. BMJ Open Diabetes Res Care 2020; 8:8/1/e001220. [PMID: 32719077 PMCID: PMC7389515 DOI: 10.1136/bmjdrc-2020-001220] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Revised: 06/14/2020] [Accepted: 06/16/2020] [Indexed: 01/08/2023] Open
Abstract
INTRODUCTION In immune-mediated inflammatory diseases, there is a lack of -estimates of glucocorticoid dose-response diabetes risk that consider changes in prescribed dose over time and disease activity. RESEARCH DESIGN AND METHODS Population-based longitudinal analysis of electronic health records from the UK Clinical Practice Research Datalink, linked to hospital admissions and the mortality registry (1998-2017). We included 100 722 adult patients without diabetes history, diagnosed with giant cell arteritis or polymyalgia rheumatica (n=32 593), inflammatory bowel disease (n=29 272), rheumatoid arthritis (n=28 365), vasculitis (n=6082), or systemic lupus erythematosus (n=4410). We estimated risks and HRs of type 2 diabetes associated with time-variant daily and total cumulative prednisolone-equivalent glucocorticoid dose using Cox regression methods. RESULTS Average patient age was 58.6 years, 65 469 (65.0%) were women and 8858 (22.6%) had a body mass index (BMI) ≥30 kg/m2. Overall, 8137 (8.1%) people developed type 2 diabetes after a median follow-up of 4.9 years. At 1 year, the cumulative risk of diabetes increased from 0.9% during periods of non-use to 5.0% when the daily prednisolone-equivalent dose was ≥25.0 mg. We found strong dose-dependent associations for all immune-mediated diseases, BMI levels and underlying disease duration, even after controlling for periods of active systemic inflammation. Adjusted HR for a <5.0 mg daily dose versus non-use was 1.90, 95% CI 1.44 to 2.50; range 1.70 for rheumatoid arthritis to 2.93 for inflammatory bowel disease. CONCLUSIONS We report dose-dependent risks of type 2 diabetes associated with glucocorticoid use for six common immune-mediated inflammatory diseases. These results underline the need for regular diabetic risk assessment and testing during glucocorticoid therapy in these patients.
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Affiliation(s)
- Jianhua Wu
- School of Dentistry, University of Leeds, Leeds, UK
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Hossain IT, Sanghi P, Manzouri B. Pharmacotherapeutic management of atopic keratoconjunctivitis. Expert Opin Pharmacother 2020; 21:1761-1769. [PMID: 32602382 DOI: 10.1080/14656566.2020.1786534] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Atopic keratoconjunctivitis (AKC) is a form of allergic eye disease that can have sight threating implications. Prevalence is underestimated due to scarce published data and treatment is expanding as a result of limitations of current strategies. This article aims to provide an up-to-date overview of AKC and summarize current and upcoming management. AREAS COVERED The authors provide history, immunopathogenesis, and summary of the clinical manifestations of AKC as well as presenting a review of the evidence in relation to treatment options including mast cell stabilizers, antihistamines, corticosteroids, and immunomodulatory drugs based on clinical trials. Future trends, drug targets, and novel delivery drug systems are also highlighted in this review. EXPERT OPINION Previously established treatment strategies of AKC had relied on corticosteroids, but the side effects of long-term therapy resulted in the expansion into the use of immunomodulatory drugs such as tacrolimus and ciclosporin. However, these too provide limited success due to the suboptimal structural properties of the current molecules. The ideal molecule should generate maximum permeability across the multi-layered structure of the cornea, be able to be formulated into eye drops for ease of application with minimal dosing and for maximal clinical effect.
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Affiliation(s)
- Ibtesham T Hossain
- Department of Ophthalmology, Queens Hospital, Barking Havering and Redbridge University Hospitals NHS Trust , Romford, UK
| | - Priyanka Sanghi
- Department of Ophthalmology, Queens Hospital, Barking Havering and Redbridge University Hospitals NHS Trust , Romford, UK
| | - Bita Manzouri
- Department of Ophthalmology, Queens Hospital, Barking Havering and Redbridge University Hospitals NHS Trust , Romford, UK
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Nicolas S, Rochet N, Gautier N, Chabry J, Pisani DF. The adiponectin receptor agonist AdipoRon normalizes glucose metabolism and prevents obesity but not growth retardation induced by glucocorticoids in young mice. Metabolism 2020; 103:154027. [PMID: 31778708 DOI: 10.1016/j.metabol.2019.154027] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 11/08/2019] [Accepted: 11/22/2019] [Indexed: 12/21/2022]
Abstract
OBJECTIVE Glucocorticoids (GCs) are highly effective anti-inflammatory and immunosuppressive drugs. However, prolonged GC therapy may cause numerous adverse effects leading to diabetes and obesity, as well as bone disorders such as osteoporosis in adults and growth retardation in children and adolescents. Prevention and care of the GC-induced adverse effects remain challenging. We have previously demonstrated the efficacy of a treatment with a non-peptidic agonist of adiponectin receptors, AdipoRon, to reverse behaviour disorders and fat mass gain induced by long-term GC treatment. In this work, we have established a relevant model of GC-induced growth and metabolic disorders and determined that AdipoRon is a potential therapeutic tool to reverse these metabolic disturbances. METHODS 5-Week-old mice were treated continuously with or without corticosterone (35 mg/L) in drinking water for seven consecutive weeks. Taking advantage of this mouse model displaying various growth and metabolic disorders, we assayed whether AdipoRon (daily intraperitoneal injection of 1 mg/kg/day for the last 20 days) might prevent the GC-induced adverse effects. The control group was treated with vehicle only. Nutritional behaviors and metabolic parameters were followed-up throughout the treatment. Serum insulin and leptin levels were measured by ELISA. Computed tomography and histological analysis of adipose tissue were assessed at the end of the experimental procedure. RESULTS We found that GC treatment in young mice resulted in continuously increased body weight gain associated with a food intake increase. Compared to vehicle-, GC-treated mice displayed early major hyperleptinemia (up to 6-fold more) and hyperinsulinemia (up to 20-fold more) maintained throughout the treatment. At the end of the experimental procedure, GC-treated mice displayed bone growth retardation (e.g. femur length 15.1 versus 14.0 mm, P < 0.01), higher abdominal adipose tissue volume (4.1 versus 2.3, P < 0.01) and altered glucose metabolism compared to control mice. Interestingly, AdipoRon prevented GC-induced effects on energy metabolism such as abdominal adiposity, insulinemia and leptinemia. However, AdipoRon failed to counteract bone growth retardation. CONCLUSION We characterized the very early pathological steps induced by long-term GC in young mice in a relevant model, including growth retardation, fat mass gain and glucose homeostasis dysregulation. The adiponectin system stimulation enabled normalization of the adipose tissue and metabolic features of GC-treated mice. Adiponectin receptor agonists such as AdipoRon might constitute a novel way to counteract some GC-induced adverse effects.
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Affiliation(s)
- Sarah Nicolas
- Université Côte d'Azur, CNRS, Institut de Pharmacologie Moléculaire et Cellulaire UMR 7275, 660 route des lucioles, Sophia Antipolis, 06560 Valbonne, France
| | - Nathalie Rochet
- Université Côte d'Azur, CNRS, Inserm, Institut de Biologie Valrose UMR 7277, 28 avenue de Valombrose, 06107 Nice, France
| | - Nadine Gautier
- Université Côte d'Azur, CNRS, Inserm, Institut de Biologie Valrose UMR 7277, 28 avenue de Valombrose, 06107 Nice, France
| | - Joëlle Chabry
- Université Côte d'Azur, CNRS, Institut de Pharmacologie Moléculaire et Cellulaire UMR 7275, 660 route des lucioles, Sophia Antipolis, 06560 Valbonne, France.
| | - Didier F Pisani
- Université Côte d'Azur, CNRS, Laboratoire de PhysioMédecine Moléculaire UMR7370, 28 avenue de Valombrose, 06107 Nice, France.
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Alessi J, de Oliveira GB, Schaan BD, Telo GH. Dexamethasone in the era of COVID-19: friend or foe? An essay on the effects of dexamethasone and the potential risks of its inadvertent use in patients with diabetes. Diabetol Metab Syndr 2020; 12:80. [PMID: 32922517 PMCID: PMC7476640 DOI: 10.1186/s13098-020-00583-7] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 08/18/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The disclosure in the media of a benefit with the use of dexamethasone in patients with COVID-19 infection sets precedents for self-medication and inappropriate use of corticosteroids. METHODS This is a critical interpretive synthesis of the data available in the literature on the effects of the use of corticosteroids and the impact that their indiscriminate use may have on patients with diabetes. Reviews and observational and experimental studies published until June 18, 2020 were selected. RESULTS Corticosteroids are substances derived from cholesterol metabolism that interfere with multiple aspects of glucose homeostasis. Interactions between corticoid receptors and target genes seem to be among the mechanisms responsible for the critical functions of glucocorticoids for survival and anti-inflammatory effects observed with these medications. Corticosteroids increase hepatic gluconeogenesis, reduce peripheral use of glucose and increase insulin levels. Previous studies have shown that glucocorticoids have a pro-adipogenic function, increasing deposition of abdominal fat, and lead to glucose intolerance and hypertriglyceridemia. In addition, these drugs play a role in controlling liver metabolism and can lead to the development of hepatic steatosis. Glucocorticoids reduce the recruitment of osteoblasts and increase the number of osteoclasts, which results in increased bone resorption and greater bone fragility. Moreover, these medications cause water and sodium retention and increase the response to circulating vasoconstrictors, which results in increased blood pressure levels. Chronic or high-dose use of corticosteroids can, by itself, lead to the onset of diabetes. For those who were already diagnosed with diabetes, studies show that chronic use of corticosteroids leads to a 94% higher risk of hospitalization due to diabetes complications. In addition to the direct effects on glycemic control, the effects on arterial pressure control, lipids and bone metabolism also have a potential for severe consequences in patients with diabetes. CONCLUSION Fear and uncertainty toward a potentially serious infection may lead people to self-medication and the inappropriate and abusive use of corticosteroids. More than ever, it is necessary for health professionals to be alert and able to predict damages related to the use of these drugs, which is the first step to minimize the potential damages to come.
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Affiliation(s)
- Janine Alessi
- Medical Science Program: Endocrinology, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
- Internal Medicine Department, Hospital São Lucas-Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, Brazil
- Endocrinology Division, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - Giovana B. de Oliveira
- School of Medicine, Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, Brazil
| | - Beatriz D. Schaan
- Medical Science Program: Endocrinology, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
- School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
- Endocrinology Division, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
- National Institute of Science and Technology for Health Technology Assessment (IATS), CNPq, Porto Alegre, Brazil
| | - Gabriela H. Telo
- Internal Medicine Department, Hospital São Lucas-Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, Brazil
- School of Medicine, Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, Brazil
- National Institute of Science and Technology for Health Technology Assessment (IATS), CNPq, Porto Alegre, Brazil
- Medicine and Health Sciences Program, Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, Brazil
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Yancey KL, Lowery AS, Chandra RK, Chowdhury NI, Turner JH. Advanced age adversely affects chronic rhinosinusitis surgical outcomes. Int Forum Allergy Rhinol 2019; 9:1125-1134. [PMID: 31454179 PMCID: PMC6773466 DOI: 10.1002/alr.22404] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2019] [Revised: 07/09/2019] [Accepted: 07/18/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Patient-specific and disease-specific factors shape the course of chronic rhinosinusitis (CRS) and its response to treatment, with optimal management involving interventions tailored to these factors. Recent evidence suggests CRS inflammatory signatures depend on age. The objective of this study was to determine whether age also influences quality-of-life (QOL) and postoperative outcomes. METHODS Retrospective analysis of prospectively collected QOL data from 403 adults with medically refractory CRS who underwent functional endoscopic sinus surgery (FESS) at a tertiary care medical center between 2014 and 2018 was undertaken. Total and subdomain scores from the 22-item Sino-Nasal Outcome Test (SNOT-22) and the Short Form 8 Health Survey (SF-8) measure of general health completed at preoperative and postoperative visits were reviewed. RESULTS Patients were divided into young (18 to 39 years, n = 100), middle-aged (40 to 59 years, n = 172), and elderly (≥60 years, n = 131) groups. Baseline total SNOT-22 scores differed between groups (p = 0.01), with middle-aged patients having the highest symptom burden and elderly patients having the lowest. Similar patterns were observed for SNOT-22 subdomains. Elderly patients reported smaller improvements and were less likely to achieve a minimally important clinical difference. CRS patients had worse SF-8 scores compared to the general population, and elderly patients were the least likely to match population norms following surgery. Age was an independent predictor of QOL outcomes after FESS. CONCLUSION Age may play a significant role in CRS pathophysiology, symptom burden, and surgical outcomes. Elderly patients report smaller improvements in disease-specific and general health QOL after surgery. CRS management in the elderly population should incorporate age-dependent differences in symptom burden and expectations into treatment algorithms.
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Affiliation(s)
- Kristen L Yancey
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Anne S Lowery
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Rakesh K Chandra
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Naweed I Chowdhury
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Justin H Turner
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, TN
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Leung JL, Owen CE, Buchanan RRC, Liew DFL. Management of polymyalgia rheumatica in older people. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2019. [DOI: 10.1002/jppr.1610] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Jessica L. Leung
- Department of Rheumatology Austin Health Melbourne Australia
- The University of Melbourne Melbourne Australia
| | - Claire E. Owen
- Department of Rheumatology Austin Health Melbourne Australia
- The University of Melbourne Melbourne Australia
| | - Russell R. C. Buchanan
- Department of Rheumatology Austin Health Melbourne Australia
- The University of Melbourne Melbourne Australia
| | - David F. L. Liew
- Department of Rheumatology Austin Health Melbourne Australia
- The University of Melbourne Melbourne Australia
- Department of Clinical Pharmacology and Therapeutics Austin Health Melbourne Australia
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Ridolo E, Kihlgren P, Pellicelli I, Nizi MC, Pucciarini F, Incorvaia C. Atopic Keratoconjunctivitis: Pharmacotherapy for the Elderly. Drugs Aging 2019; 36:581-588. [PMID: 31055787 DOI: 10.1007/s40266-019-00676-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Among the different forms of allergic conjunctivitis, atopic keratoconjunctivitis has distinct characteristics, defined by a more common onset in late adolescence or early adulthood, but also affecting the elderly, and with a higher prevalence in male individuals. However, the prevalence of atopic keratoconjunctivitis is scarcely investigated, and the data are often uncertain because other allergic nasal or respiratory disorders occur concomitantly. Mast cells, eosinophils, basophils, and T cells are involved in the pathogenesis of atopic keratoconjunctivitis. Despite its denomination as atopic, negative responses to skin tests or in-vitro immunoglobulin E tests are common. In fact, atopic keratoconjunctivitis can be attributed to a combination of T-helper-1 and T-helper-2 responses, but a higher prominence for T-helper-1 cells was found. The most common symptoms of atopic keratoconjunctivitis are bilateral ocular itching, burning, and tearing with a perennial presentation, although some patients may have seasonal exacerbations in winter or summer. Other symptoms such as photophobia, blurred vision, and mucous chewy discharge, owing to the accumulation of cells and mucin, may occur. The diagnosis of atopic keratoconjunctivitis is mainly clinical, as accepted diagnostic criteria or laboratory tests are not available. The treatment of atopic keratoconjunctivitis is aimed at controlling symptoms, decreasing relapse and exacerbations, and reducing vision loss. Therapeutic options comprise topical ophthalmic drops, including cromones, antihistamines, corticosteroids, and calcineurin inhibitors. Topical ointments are also available for corticosteroids and calcineurin inhibitors. Severe forms may require systemic medications including antihistamines, corticosteroids, and calcineurin inhibitors. Atopic keratoconjunctivitis therapy in the elderly does not differ from the adult population, but the occurrence of multi-morbidities and concomitant drug treatment, which are common in this age group, requires a careful evaluation to determine appropriate and personalized treatment.
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Affiliation(s)
- Erminia Ridolo
- Allergy and Clinical Immunology, Department of Medicine and Surgery, University of Parma, Via Gramsci n.14, 43126, Parma, Italy.
| | - P Kihlgren
- Allergy and Clinical Immunology, Department of Medicine and Surgery, University of Parma, Via Gramsci n.14, 43126, Parma, Italy
| | - I Pellicelli
- Allergy and Clinical Immunology, Department of Medicine and Surgery, University of Parma, Via Gramsci n.14, 43126, Parma, Italy
| | - M C Nizi
- Allergy and Clinical Immunology, Department of Medicine and Surgery, University of Parma, Via Gramsci n.14, 43126, Parma, Italy
| | - F Pucciarini
- Allergy and Clinical Immunology, Department of Medicine and Surgery, University of Parma, Via Gramsci n.14, 43126, Parma, Italy
| | - C Incorvaia
- Cardiac/Pulmonary Rehabilitation Unit, ASST Pini-CTO, Milan, Italy
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Tibble H, Tsanas A, Horne E, Horne R, Mizani M, Simpson CR, Sheikh A. Predicting asthma attacks in primary care: protocol for developing a machine learning-based prediction model. BMJ Open 2019; 9:e028375. [PMID: 31292179 PMCID: PMC6624024 DOI: 10.1136/bmjopen-2018-028375] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 04/02/2019] [Accepted: 06/04/2019] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Asthma is a long-term condition with rapid onset worsening of symptoms ('attacks') which can be unpredictable and may prove fatal. Models predicting asthma attacks require high sensitivity to minimise mortality risk, and high specificity to avoid unnecessary prescribing of preventative medications that carry an associated risk of adverse events. We aim to create a risk score to predict asthma attacks in primary care using a statistical learning approach trained on routinely collected electronic health record data. METHODS AND ANALYSIS We will employ machine-learning classifiers (naïve Bayes, support vector machines, and random forests) to create an asthma attack risk prediction model, using the Asthma Learning Health System (ALHS) study patient registry comprising 500 000 individuals across 75 Scottish general practices, with linked longitudinal primary care prescribing records, primary care Read codes, accident and emergency records, hospital admissions and deaths. Models will be compared on a partition of the dataset reserved for validation, and the final model will be tested in both an unseen partition of the derivation dataset and an external dataset from the Seasonal Influenza Vaccination Effectiveness II (SIVE II) study. ETHICS AND DISSEMINATION Permissions for the ALHS project were obtained from the South East Scotland Research Ethics Committee 02 [16/SS/0130] and the Public Benefit and Privacy Panel for Health and Social Care (1516-0489). Permissions for the SIVE II project were obtained from the Privacy Advisory Committee (National Services NHS Scotland) [68/14] and the National Research Ethics Committee West Midlands-Edgbaston [15/WM/0035]. The subsequent research paper will be submitted for publication to a peer-reviewed journal and code scripts used for all components of the data cleaning, compiling, and analysis will be made available in the open source GitHub website (https://github.com/hollytibble).
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Affiliation(s)
- Holly Tibble
- Usher Institute of Population Health Sciences and Informatics, Edinburgh Medical School, College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK
- Asthma UK Centre for Applied Research, Edinburgh, UK
| | - Athanasios Tsanas
- Usher Institute of Population Health Sciences and Informatics, Edinburgh Medical School, College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK
- Asthma UK Centre for Applied Research, Edinburgh, UK
| | - Elsie Horne
- Usher Institute of Population Health Sciences and Informatics, Edinburgh Medical School, College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK
- Asthma UK Centre for Applied Research, Edinburgh, UK
| | - Robert Horne
- Asthma UK Centre for Applied Research, Edinburgh, UK
- University College London, London, UK
| | - Mehrdad Mizani
- Usher Institute of Population Health Sciences and Informatics, Edinburgh Medical School, College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK
- Asthma UK Centre for Applied Research, Edinburgh, UK
| | - Colin R Simpson
- Asthma UK Centre for Applied Research, Edinburgh, UK
- School of Health, Victoria University of Wellington, Wellington, UK
| | - Aziz Sheikh
- Usher Institute of Population Health Sciences and Informatics, Edinburgh Medical School, College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK
- Asthma UK Centre for Applied Research, Edinburgh, UK
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Chiu WL, Churilov L, Lim CH, Tan A, Nedumannil R, Lau LH, Lew J, Hachem M, Kong A, Robbins R, Sutcliffe H, Lam Q, Lee A, Djukiadmodjo F, Nanayakkara N, Zajac JD, Ekinci EI. Routine HbA1c among hematology and oncology inpatients: Diabetes-status and hospital-outcomes. Diabetes Res Clin Pract 2019; 152:71-78. [PMID: 31082446 DOI: 10.1016/j.diabres.2019.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Revised: 04/25/2019] [Accepted: 05/03/2019] [Indexed: 01/08/2023]
Abstract
AIMS Using routine HbA1c measurement to determine the prevalence of diabetes mellitus (known and previously unrecognized) and their hospital outcomes among hematology and oncology inpatients. METHODS This was a prospective, observational study. Routine automated HbA1c testing was performed in all hematology and oncology inpatients aged ≥54 years at a tertiary hospital, July 2013-January 2015. The outcome measures were: (i) prevalence of known and previously unrecognized diabetes, and (ii) hospital outcomes: length-of-stay (LOS), intensive-care-unit (ICU) admission, 30-day/18-month readmission, and 18-month mortality. RESULTS Over the 18-month study period, 1076 inpatients aged ≥54 years were admitted to hematology (n = 298) and oncology (n = 778) units: 21% had known diabetes and 7% had previously unrecognized diabetes. Patients with known diabetes had a longer LOS (IRR: 1.18, 95%CI: 1.02-1.37, p = 0.03), compared to those without diabetes, adjusting for age, hemoglobin level, estimated-glomerular-filtration-rate, admission specialty unit, Charlson's comorbidity index score, and glucocorticoid exposure. No significant differences were observed in ICU admission, 30-day/18-month readmission, and 18-month mortality among patients with known, previously unrecognized and no diabetes (p ≥ 0.05). CONCLUSIONS Approximately one in five hematology or oncology inpatients aged ≥54 years had known diabetes, and one in fourteen had previously unrecognized diabetes. Those with known diabetes had a longer hospital stay. Routine HbA1c measurement is can be useful for identifying previously unrecognized diabetes, particularly among patients with high glucocorticoid exposure. Further study is required to determine cost-effectiveness in screening for unrecognized diabetes and optimal management of these patients.
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Affiliation(s)
- Wei-Ling Chiu
- Department of Endocrinology, Austin Health, 145 Studley Road, Heidelberg, Victoria 3084, Australia.
| | - Leonid Churilov
- The Florey Institute of Neuroscience & Mental Health, Heidelberg, Victoria 3084, Australia; University of Melbourne - Austin Health, Department of Medicine, Heidelberg, Victoria 3084, Australia.
| | - Chee-Hau Lim
- Department of Endocrinology, Austin Health, 145 Studley Road, Heidelberg, Victoria 3084, Australia
| | - Alanna Tan
- Department of Endocrinology, Austin Health, 145 Studley Road, Heidelberg, Victoria 3084, Australia.
| | - Rithin Nedumannil
- Department of Endocrinology, Austin Health, 145 Studley Road, Heidelberg, Victoria 3084, Australia
| | - Lik-Hui Lau
- Department of Endocrinology, Austin Health, 145 Studley Road, Heidelberg, Victoria 3084, Australia
| | - Jeremy Lew
- University of Melbourne, Grattan Street, Parkville, Victoria 3010, Australia
| | - Mariam Hachem
- University of Melbourne - Austin Health, Department of Medicine, Heidelberg, Victoria 3084, Australia.
| | - Alvin Kong
- University of Melbourne, Grattan Street, Parkville, Victoria 3010, Australia
| | - Raymond Robbins
- Department of Strategy, Quality & Service Redesign, Austin Health, 145 Studley Road, Heidelberg, Victoria 3084, Australia.
| | - Harvey Sutcliffe
- Pathology IT Service, Austin Pathology, Heidelberg, Victoria 3084, Australia.
| | - Que Lam
- Pathology IT Service, Austin Pathology, Heidelberg, Victoria 3084, Australia.
| | - Andrew Lee
- Clinical Informatics Unit, Austin Health, Heidelberg, Victoria 3084, Australia.
| | - Frida Djukiadmodjo
- Department of Endocrinology, Austin Health, 145 Studley Road, Heidelberg, Victoria 3084, Australia
| | - Natalie Nanayakkara
- Department of Endocrinology, Austin Health, 145 Studley Road, Heidelberg, Victoria 3084, Australia.
| | - Jeffrey D Zajac
- Department of Endocrinology, Austin Health, 145 Studley Road, Heidelberg, Victoria 3084, Australia; University of Melbourne - Austin Health, Department of Medicine, Heidelberg, Victoria 3084, Australia.
| | - Elif I Ekinci
- Department of Endocrinology, Austin Health, 145 Studley Road, Heidelberg, Victoria 3084, Australia; University of Melbourne - Austin Health, Department of Medicine, Heidelberg, Victoria 3084, Australia.
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Yang J, Wang X, Li Y, Lu G, Lu X, Guo D, Wang W, Liu C, Xiao Y, Han N, He S. Efficacy and safety of steroid in the prevention of esophageal stricture after endoscopic submucosal dissection: A network meta-analysis. J Gastroenterol Hepatol 2019; 34:985-995. [PMID: 30566746 DOI: 10.1111/jgh.14580] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Revised: 12/05/2018] [Accepted: 12/10/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIM Even though endoscopic submucosal dissection is an important endoscopic resection technique for gastrointestinal neoplasms, there are chances that postoperative esophageal stricture might take place as a side effect. Steroid applications were reported to be effective for the prevention of stricture formation. Therefore, this study aims to evaluate the efficacy and safety of different steroid applications. METHODS Eligible studies published on PubMed, the Cochrane Library, Embase, Web of Science, and Chinese Biomedical Literature Database before August 2018 were reviewed. The preventions were divided as placebo/no treatment, long-term oral steroid (LOS), median-term oral steroid, short-term oral steroid, single-dose steroid injection, multiple-dose steroid injection, topical superficial steroid, steroid injection combined with oral steroid, and preemptive endoscopic balloon dilatation. The primary outcomes were postoperative esophageal stricture rate and endoscopic balloon dilatation sessions required. Complications were also analyzed. RESULTS A total of 19 studies were included. The network meta-results illustrated that compared with the placebo, all kinds of steroid interventions were associated with lower rates of postoperative esophageal stenosis and less number of endoscopic balloon dilatation sessions. Moreover, combined therapy was no better than single regimen therapy. No significant differences between various steroid applications in the incidence of complications were spotted during this study. Based on the results of the network and clustered ranking, LOS might be the superior prevention for postoperative stricture with satisfying efficacy. CONCLUSION The present study showed that LOS appears to be the optimal prevention method for postoperative stricture formation.
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Affiliation(s)
- Jiahui Yang
- Department of Gastroenterology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Xin Wang
- Department of Gastroenterology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Yarui Li
- Department of Gastroenterology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Guifang Lu
- Department of Gastroenterology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Xinlan Lu
- Department of Gastroenterology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Dan Guo
- Department of Gastroenterology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Wancong Wang
- Department of Gastroenterology, The Fifth Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Chuan Liu
- Department of Gastroenterology, The Fifth Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Ye Xiao
- Department of Gastroenterology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Nini Han
- Department of Gastroenterology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Shuixiang He
- Department of Gastroenterology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
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Bretoni A, Ferrario L, Foglia E. HTA and innovative treatments evaluation: the case of metastatic castration-resistant prostate cancer. CLINICOECONOMICS AND OUTCOMES RESEARCH 2019; 11:283-300. [PMID: 31114269 PMCID: PMC6489625 DOI: 10.2147/ceor.s189436] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Accepted: 03/13/2019] [Indexed: 01/22/2023] Open
Abstract
Purpose: To investigate the implications of the introduction of two hormonal therapies, abiraterone acetate + prednisone (AA+P) and enzalutamide (ENZA), for the treatment of naïve patients with metastatic castration-resistant prostate cancer (mCRPC) in the Italian setting. Methods: In 2017–2018, a Health Technology Assessment was conducted in Italy, considering the National Healthcare Service (NHS) perspective. Data were retrieved from literature evidence, economic evaluations, and qualitative questionnaires, considering the 9 EUnetHTA dimensions, and a final multi-criteria approach. Results: On the basis of mCRPC prevalence and incidence rates in Italy, the analysis considered 11,212 males eligible to either AA+P or ENZA treatments. Both drugs led to an improvement of the patients' overall survival, with respect to the standard of care, composed of docetaxel chemotherapy. However, AA+P showed a higher rate of drug-related moderate adverse events and a monitoring activities incidence superior to ENZA (+70%, p-value=0.00), which led to a major resources absorption (€ 1,056.02 vs € 316.25, p-value=0.00), whereas ENZA showed a better cost-effectiveness average value (CEV: 54,586.12 vs 57,624.15). Economic savings ranging from 1.46% to 1.61% emerged for the NHS, as well as organizational advantages, with fewer minutes required for the mCRPC management (AA+P: 815 mins vs ENZA: 500 mins). According to experts’ perceptions, based on a 7-item Likert scale (ranging from −3 to +3), similar results emerged on ethical and social impact (ENZA: 1.35 vs AA+P: 1.48, p-value>0.05), and on legal dimension (ENZA: 0.67 vs AA+P: 0.67, p-value>0.05), since both drugs improved the patients’ quality of life and received approval for use. High-level perceptions related to ENZA adoption emerged with regard to equity (ENZA: 0.69 vs AA+P: 0.25, p-value<0.05), since it is cortisone-free. Multi-criteria approach analysis highlighted a higher score of ENZA than comparator (0.79 vs 0.60, p-value=0.00). Conclusion: The evidence-based information underlined the advantages of ENZA and AA+P treatments as therapeutic options for mCRPC patients. In the appraisal phase, the higher score than the comparator suggested ENZA as the preferred treatment for mCRPC.
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Affiliation(s)
- Alberto Bretoni
- Centre for Health Economics, Social and Health Care Management, LIUC - Università Cattaneo, Castellanza, Italy
| | - Lucrezia Ferrario
- Centre for Health Economics, Social and Health Care Management, LIUC - Università Cattaneo, Castellanza, Italy
| | - Emanuela Foglia
- Centre for Health Economics, Social and Health Care Management, LIUC - Università Cattaneo, Castellanza, Italy
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Duricova D, Pariente B, Sarter H, Fumery M, Leroyer A, Charpentier C, Armengol-Debeir L, Peyrin-Biroulet L, Savoye G, Gower-Rousseau C. Impact of age at diagnosis on natural history of patients with elderly-onset ulcerative colitis: A French population-based study. Dig Liver Dis 2018; 50:903-909. [PMID: 29739650 DOI: 10.1016/j.dld.2018.04.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2017] [Revised: 04/04/2018] [Accepted: 04/10/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND Recent population-based study of elderly-onset Crohn's disease patients reported age-related differences in disease phenotype and outcome. AIMS The aim was to assess the impact of age at diagnosis on natural history of elderly-onset ulcerative colitis patients with emphasis on disease presentation, phenotype and treatment. METHODS Elderly-onset patients with ulcerative colitis (≥60 years at diagnosis) registered in a French population-based Registry EPIMAD (1988-2006) were included. Demographic and clinical data at diagnosis and at maximal follow-up were collected using predefined questionnaire. RESULTS Four-hundred and sixty-five elderly-onset ulcerative colitis patients were included (median follow-up 6.2 years); 276 (59%) were <70 and 189 (41%) ≥70 years at diagnosis. Patients aged <70 years presented with more rectal bleeding (86% vs. 79%, p = .06) and abdominal pain (44% vs. 34%, p = .04) while those ≥70 years had higher rate of left-sided colitis (62% vs. 49%; p = .02). Cumulative exposure to 5-ASA, corticosteroids and immunosuppressants was similar between the groups as well as surgery rate. However, patients <70 years were significantly more steroid-resistant than older individuals (12% vs. 3%, p < .05) while no significant difference in steroid-dependency was observed. CONCLUSION Patients with elderly-onset ulcerative colitis differed in presentation, disease phenotype and response to medication with respect to age at diagnosis.
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Affiliation(s)
- Dana Duricova
- Public Health, Epidemiology and Economic Health, Epimad Registry, Hospital & University Centre of Clinical Research, Lille University and Hospital, France; IBD Clinical and Research Centre, ISCARE I.V.F., a.s., Charles University, Prague
| | - Benjamin Pariente
- Gastroenterology Unit, Hôpital Huriez, Lille University Hospital, France
| | - Hélène Sarter
- Public Health, Epidemiology and Economic Health, Epimad Registry, Hospital & University Centre of Clinical Research, Lille University and Hospital, France; Lille Inflammation Research International Center LIRIC-UMR 995 Inserm Lille 2 University, CHRU de Lille, Lille, France
| | - Mathurin Fumery
- Gastroenterology Unit, Epimad Registry, CHU Amiens Sud, Amiens University Hospital, France; Lille Inflammation Research International Center LIRIC-UMR 995 Inserm Lille 2 University, CHRU de Lille, Lille, France
| | - Ariane Leroyer
- Public Health, Epidemiology and Economic Health, Epimad Registry, Hospital & University Centre of Clinical Research, Lille University and Hospital, France
| | - Cloe Charpentier
- Gastroenterology Unit, Epimad Registry, Charles Nicolle Hospital, Rouen University Hospital, France
| | - Laura Armengol-Debeir
- Gastroenterology Unit, Epimad Registry, Charles Nicolle Hospital, Rouen University Hospital, France
| | | | - Guillaume Savoye
- Gastroenterology Unit, Epimad Registry, Charles Nicolle Hospital, Rouen University Hospital, France
| | - Corinne Gower-Rousseau
- Public Health, Epidemiology and Economic Health, Epimad Registry, Hospital & University Centre of Clinical Research, Lille University and Hospital, France; Lille Inflammation Research International Center LIRIC-UMR 995 Inserm Lille 2 University, CHRU de Lille, Lille, France.
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Montserrat-Capdevila J, Godoy P, Marsal JR, Ortega M, Pifarré J, Alsedà M, Castañ MT, Barbé F. Mental disorders in chronic obstructive pulmonary diseases. Perspect Psychiatr Care 2018; 54:398-404. [PMID: 29577318 DOI: 10.1111/ppc.12274] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2017] [Revised: 02/22/2018] [Accepted: 02/24/2018] [Indexed: 11/28/2022] Open
Abstract
PURPOSE Anxiety and depression are underdiagnosed in chronic obstructive pulmonary disease (COPD) patients. Few studies have tried to identify their association with hospitalization (severe exacerbation). The objective of this study was to determine whether the anxiety/depression was associated with severe exacerbation. DESIGN AND METHODS A prospective cohort study, based on a sample of 512 patients diagnosed with COPD originating from primary care in a rural area in Lleida (Spain) and monitored between November 1, 2012 and October 31, 2014. For each patient, variables of interest were recorded; they were administered the HADS (Hospital Anxiety and Depression Scale) test to determine the possible presence of anxiety/depression, and its association with severe exacerbation was analyzed using a logistic regression model. FINDINGS Initially, the prevalence of anxiety/depression was 15.6%. The incidence of global hospitalization in the first year was 8.2% and 11.3% in the second year. In patients with anxiety/depression, it increased to 17.5% in the first year and 18.8% in the second year. In the multivariate regression model, the diagnosis of anxiety/depression almost doubled the risk of hospitalization (OR = 1.94) (p < .041). PRACTICE IMPLICATIONS Anxiety and depression are associated with an increased risk of hospitalization. Intervention studies are needed to evaluate the effects of anxiety/depression in the hospitalization.
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Affiliation(s)
- Josep Montserrat-Capdevila
- Biomedical Research Institute (IRB) of Lleida, Catalan Institute of Health (ICS), UGA Terres de l'Urgell (Consultori Local de Bellvís-Els Arcs), Lleida, Catalonia, Spain
| | - Pere Godoy
- Public Health Agency of Catalonia, Health Department, Biomedical Research Institute (IRB) of Lleida, University of Lleida, Faculty of Medicine, Lleida, Catalonia, Spain.,CIBER de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
| | - Josep Ramon Marsal
- Primary Care Research Institute (IDIAP) Jordi Gol, Universitat Autònoma of Barcelona, University Hospital Vall d'Hebron, Cardiovascular Department, Epidemiology Unit, Lleida, Catalonia, Spain
| | - Marta Ortega
- Primary Care Research Institute (IDIAP) Jordi Gol, Universitat Autònoma of Barcelona, Catalan Institute of Health (ICS), Lleida, Catalonia, Spain
| | - Josep Pifarré
- University Hospital Santa Maria, Psychiatry Department, Biomedical Research Institute (IRB) of Lleida, University of Lleida, Faculty of Medicine, Lleida, Catalonia, Spain
| | - Miquel Alsedà
- Public Health Agency of Catalonia, Health Department, Biomedical Research Institute (IRB) of Lleida, University of Lleida, Faculty of Medicine, Lleida, Catalonia, Spain
| | - Maria Teresa Castañ
- Biomedical Research Institute (IRB) of Lleida, Catalan Institute of Health (ICS), ABS Balaguer, Lleida, Catalonia, Spain
| | - Ferran Barbé
- University Hospital Arnau de Vilanova, Biomedical Research Institute (IRB) of Lleida, Respiratory Diseases Group, Biomedical Research Centre/Respiratory Diseases Network (CIBERES), Madrid, Spain
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Machado FVC, Pitta F, Hernandes NA, Bertolini GL. Physiopathological relationship between chronic obstructive pulmonary disease and insulin resistance. Endocrine 2018; 61:17-22. [PMID: 29512058 DOI: 10.1007/s12020-018-1554-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Accepted: 01/31/2018] [Indexed: 12/16/2022]
Abstract
PURPOSE Chronic obstructive pulmonary disease (COPD) is characterized by persistent and progressive airflow obstruction that is associated with an abnormal chronic inflammatory response in the airways and lungs to noxious particles. COPD often leads to physical inactivity and deconditioning that added to inappropriate/excessive inflammatory responses leads to systemic consequences. Studies have shown that metabolic syndrome and manifested diabetes are more frequent in COPD than in healthy subjects; a possible explanation is that different pathophysiological aspects of COPD can lead to insulin resistance. Thus, this mini-review aims to present the main studies suggesting a pathophysiological relationship between COPD and insulin resistance. METHODS A review of literature was conducted using PubMed and Web of Science databases with the aim of searching for studies supporting a relationship between COPD and insulin resistance. RESULTS A physiopathological relationship between COPD and insulin resistance was found, supported in part due to common risk factors presented by these two conditions, such as smoking and physical inactivity. Also, systemic effects (worsening of physical inactivity and sedentary behavior, inflammation and oxidative stress, body composition abnormalities) and the corticosteroid treatment of patients with COPD may play a role. CONCLUSION Patients with COPD should be screened for abnormalities in insulin sensitivity in order to reduce morbidity and improve health status in this population.
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Affiliation(s)
- Felipe Vilaça Cavallari Machado
- Department of Physiotherapy, Laboratory of Research in Respiratory Physiotherapy (LFIP), State University of Londrina (UEL), Londrina, Paraná, Brazil
| | - Fabio Pitta
- Department of Physiotherapy, Laboratory of Research in Respiratory Physiotherapy (LFIP), State University of Londrina (UEL), Londrina, Paraná, Brazil
| | - Nidia Aparecida Hernandes
- Department of Physiotherapy, Laboratory of Research in Respiratory Physiotherapy (LFIP), State University of Londrina (UEL), Londrina, Paraná, Brazil
| | - Gisele Lopes Bertolini
- Department of Physiological Sciences, State University of Londrina (UEL), Londrina, Paraná, Brazil.
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Bonaventura A, Montecucco F. Steroid-induced hyperglycemia: An underdiagnosed problem or clinical inertia? A narrative review. Diabetes Res Clin Pract 2018. [PMID: 29530386 DOI: 10.1016/j.diabres.2018.03.006] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Corticosteroids are widely diffused drugs. An important side effect is the impairment of glycemic control both in patients with known diabetes and in normoglycemic ones potentially leading to steroid-induced diabetes mellitus (SIDM). In this review based on papers released on PubMed, MEDLINE, and EMBASE from January 2015 to October 2017, we summarized and discussed main updates about the definition, the diagnosis, and the pathophysiology of steroid-induced hyperglycemia (SIH), with a look to new therapies. Main alterations responsible for the diabetogenic effect of corticosteroids are a negative impact on insulin sensitivity along with a derangement on insulin secretion, explaining the typical post-prandial hyperglycemia linked to the promotion of gluconeogenesis. An early and precise diagnosis of SIH and/or SIDM is necessary, but current criteria do not seem sensible enough. As an afterthought, the treatment should be reasoned and tailored according to proposed glycemic thresholds and patient comorbidities, choosing between antidiabetic oral drugs and insulin, the latter being preferable among hospitalized patients. SIDM and SIH are frequent problems, but often underdiagnosed due to old diagnostic criteria. Dedicated guidelines universally shared are mandatory in order to harmonize the treatment of these conditions, thus overtaking single therapeutic strategies mostly arising from literature.
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Affiliation(s)
- Aldo Bonaventura
- First Clinic of Internal Medicine, Department of Internal Medicine, University of Genoa, 6 viale Benedetto XV, 16132 Genoa, Italy.
| | - Fabrizio Montecucco
- First Clinic of Internal Medicine, Department of Internal Medicine, University of Genoa, 6 viale Benedetto XV, 16132 Genoa, Italy; Ospedale Policlinico San Martino, 10 Largo Benzi, 16132 Genoa, Italy; Centre of Excellence for Biomedical Research (CEBR), University of Genoa, 9 viale Benedetto XV, 16132 Genoa, Italy
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Keyany A, Nielen JTH, Souverein PC, de Vries F, van den Bemt B. Use of parenteral glucocorticoids and the risk of new onset type 2 diabetes mellitus: A case-control study. Diabetes Res Clin Pract 2018; 139:100-106. [PMID: 29477504 DOI: 10.1016/j.diabres.2018.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Revised: 01/03/2018] [Accepted: 02/06/2018] [Indexed: 11/24/2022]
Abstract
BACKGROUND Use of oral glucocorticoids (GCs) has been associated with hyperglycaemia and type 2 diabetes mellitus (T2DM). However, unlike oral GCs, there is minimal or no data on the effect of parenteral GC use on T2DM. OBJECTIVE To assess the association between use of parenteral GCs and the risk of receiving a first prescription of a non-insulin antidiabetic drug (NIAD) as a proxy for new onset of T2DM. METHODS A population based case-control study was performed using the Clinical Practice Research Datalink (CPRD). Cases (n = 177,154) were defined as patients >18 years of age who had their first ever NIAD prescription between January 1987 and October 2013. Controls were matched by age, gender and general practitioner practice. Conditional logistic regression analyses were used to estimate the risk of NIAD prescription and use of parenteral GCs. Our analyses were statistically adjusted for lifestyle factors, comorbidities and concomitant drug use. RESULTS Although this study confirmed that oral GCs increases the risk of receiving a first prescription of a NIAD (OR 2.63 [95% CI 2.53-2.73]), there was no association between the use of parenterally administered GCs and the risk of receiving a first prescription of a NIAD (OR 0.88 [95% CI 0.76-1.02]). The number of GC prescriptions was not associated with risk of new onset T2DM compared to no parenteral GCs use; neither the type of GC. CONCLUSION Our study does not demonstrate an association between the use of parenteral GCs and the risk of new onset of T2DM.
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Affiliation(s)
- Ala Keyany
- Department of Pharmacy, Sint Maartenskliniek, Nijmegen, The Netherlands
| | - Johannes T H Nielen
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute of Pharmaceutical Sciences, Utrecht University, Utrecht, Netherlands; Department of Epidemiology, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, the Netherlands
| | - Patrick C Souverein
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute of Pharmaceutical Sciences, Utrecht University, Utrecht, Netherlands
| | - Frank de Vries
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute of Pharmaceutical Sciences, Utrecht University, Utrecht, Netherlands; Department of Epidemiology, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, the Netherlands; Department of Clinical Pharmacy and Toxicology, Maastricht University Medical Centre+, Maastricht, Netherlands.
| | - Bart van den Bemt
- Department of Pharmacy, Sint Maartenskliniek, Nijmegen, The Netherlands; Department of Pharmacy, Radboud University Medical Center, Nijmegen, The Netherlands
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44
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Advances in Managing Type 2 Diabetes in the Elderly: A Focus on Inpatient Care and Transitions of Care. Am J Ther 2018. [DOI: 10.1097/mjt.0000000000000667] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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45
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Chikani UN, Ibekwe MU, Oguonu T, Mungai L, Bisi-Onyemaechi AI, Ugege OM, Ogbonna IF, de Beaufort C. Steroid-induced impairment of glucose tolerance: Prevalence among pediatric patients on long-term steroid use in Nigeria. Pediatr Diabetes 2017; 18:942-946. [PMID: 28261934 DOI: 10.1111/pedi.12514] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Revised: 12/15/2016] [Accepted: 02/02/2017] [Indexed: 01/24/2023] Open
Abstract
INTRODUCTION Glucocorticoid (referred to from here on as simply steroid) is used for effective treatment of various inflammatory disorders since its discovery in 1940s. However, these useful drugs cause important side effects, such as impairment of glucose tolerance. We sought to determine the prevalence of steroid-induced impairment of glucose tolerance in pediatric patients on long-term steroid use. MATERIALS AND METHODS A cross-sectional, descriptive and hospital-based study. Consenting subjects who met the inclusion criteria were screened with random glucometer measurements repeated twice. An average of both readings obtained from the initial measurement of their random blood glucose (RBG) and a repeat during the next clinic visit was taken as the RBG. RESULTS Hundred patients were studied, 66 males/34 females. Subjects with nephrotic syndrome were 61 while 39 had asthma. Mean age of 10.13 years (range: 0.5-18 years); mean body mass index (BMI): 18.2 kg/m2 (range: 6.6 to 26.30 kg/m2 ). The subjects with nephrotic syndrome were on oral prednisolone while the asthmatics were on inhaled fluticasone, budesonide and oral methylprednisolone. Mean (range) duration of steroid use was 9.74 (0.5-72) months. Mean (range) RBG was 3.49 (3.3-7.5) mmol/L. None of the subjects showed abnormal RBG. However, the RBG was further categorized into low, moderate and high normal RBG. A positive correlation between longer duration of steroid use as well as high doses of both oral and inhaled steroids, and high normal RBG existed (P = .015). No statistically significant relationship existed between body mass index (BMI) percentile and RBG (P = .437). CONCLUSION Low to moderate doses of oral and inhaled steroids should be used when indicated as they are associated with lesser risk of impairment of glucose tolerance in the pediatric population.
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Affiliation(s)
- U N Chikani
- Department of Paediatrics, University of Nigeria, Nsukka, Enugu, Nigeria
| | - M U Ibekwe
- Department of Paediatrics, Federal Teaching Hospital, Abakaliki, Nigeria
| | - T Oguonu
- Department of Paediatrics, University of Nigeria, Nsukka, Enugu, Nigeria
| | - L Mungai
- Department of Paediatrics, University of Nairobi, Nairobi, Kenya
| | | | - O M Ugege
- Department of Paediatrics, Usman Danfodio University, Sokoto, Nigeria
| | - I F Ogbonna
- Department of Paediatrics, Abia State University, Okigwe, Nigeria
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Marino JS, Ruban C, Blanchette CM. The Association of COPD Exacerbations with New Onset Type 2 Diabetes among Medicare Patients. JOURNAL OF HEALTH ECONOMICS AND OUTCOMES RESEARCH 2017; 5:183-193. [PMID: 35620780 PMCID: PMC9090466 DOI: 10.36469/9810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Objective: Chronic obstructive pulmonary disease (COPD) is highly prevalent in the elderly population and typically reduces overall quality of life. Exacerbations of COPD are commonly treated with corticosteroids, a class of drug known to cause insulin resistance. The objective of this study was to assess the rate of exacerbations requiring emergency room visits, hospitalizations or any medical encounter (a combination of emergency room and hospitalizations) between COPD patients who did and did not develop type 2 diabetes. Research Design and Methods: A case-control study of COPD patients from the 2011-2012 Medicare 5% sample Limited Data Set (LDS) was conducted. Beneficiaries with at least 1 year of continuous enrollment and evidence of > 2 COPD-related claims (>1 primary diagnosis) were included in the study. Cases were defined as a beneficiary with a new claim for type 2 diabetes, whereas controls lacked evidence of type 2 diabetes (beneficiaries with evidence of non-incident type 2 diabetes were excluded). Results: Of 27 456 COPD beneficiaries, 1274 developed incident type 2 diabetes (4.6%). After matching, 2536 beneficiaries were assigned as cases (n = 1268) and controls (n = 1268). Cases in the emergency room (1.97 claims per person) (p = <0.001) and hospitalizations (2.02 claims per person) (p = <0.001) had a higher rate of exacerbations. Conclusion: Our findings suggest that patients that were hospitalized and visited the emergency room for COPD exacerbations had a greater likelihood of type 2 diabetes. Type 2 diabetes may be associated with exposure to corticosteroids as a result of the treatment for exacerbations. Future work should investigate the risk for type 2 diabetes in COPD patients treated with corticosteroids.
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Affiliation(s)
- Joseph S Marino
- Health Informatics and Outcomes Research Academy, Laboratory of Systems Physiology, Department of Kinesiology, University of North Carolina, Charlotte, NC, USA
| | - Cynthiya Ruban
- Health Informatics and Outcomes Research Academy, Department of Public Health Sciences, University of North Carolina, Charlotte, NC, USA
| | - Christopher M Blanchette
- Health Informatics and Outcomes Research Academy, Department of Public Health Sciences, University of North Carolina, Charlotte, NC, USA
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Abstract
OBJECTIVE To review therapeutic strategies for the management of patients with steroid-induced hyperglycemia. DATA SOURCES A literature search of MEDLINE/PubMed (1990 to June 2017) was conducted using the search terms steroid, glucocorticoid, corticosteroid, hyperglycemia, and diabetes as well via review of literature citations. STUDY SELECTION AND DATA EXTRACTION Relevant clinical trials and case studies focusing on pharmacological interventions in humans were reviewed for inclusion. Articles discussing islet cell transplant were excluded. DATA SYNTHESIS Hyperglycemia is a predictable adverse effect of glucocorticoid therapy, which is associated with negative outcomes, including an odds ratio of 1.36 for developing new-onset diabetes. A variety of strategies have been utilized for managing patients who are at risk of complications caused by steroid-induced hyperglycemia. Agents such as sulfonylureas, thiazolidinediones, meglitinides, metformin, dipeptidyl peptidase 4 (DPP-4) inhibitors, glucagon-like peptidase-1 agonists, and insulin have been evaluated in case studies and small clinical trials with varying degrees of success. CONCLUSIONS Since there are limited clinical data available to guide therapy, strategies that minimize the risk of adverse effects should be selected for the management of steroid-induced hyperglycemia. Therapies that may be safe and effective given current information include DPP-4 inhibitors, metformin, and weight-based neutral protamine Hagedorn insulin.
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Affiliation(s)
| | - Nicole L Metzger
- 1 Emory University Hospital, Atlanta, GA, USA.,2 Mercer University College of Pharmacy, Atlanta, GA, USA
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48
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Lin CS, Liu CC, Yeh CC, Chang YC, Chung CL, Lane HL, Shih CC, Chen TL, Liao CC. Diabetes risks and outcomes in chronic obstructive pulmonary disease patients: Two nationwide population-based retrospective cohort studies. PLoS One 2017; 12:e0181815. [PMID: 28813433 PMCID: PMC5558949 DOI: 10.1371/journal.pone.0181815] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Accepted: 07/05/2017] [Indexed: 01/27/2023] Open
Abstract
OBJECTIVE The relationship between chronic obstructive pulmonary disease (COPD) and diabetes remains incompletely understood. This study evaluated diabetes risk and post-diabetes outcomes in COPD patients with and without exacerbations. METHODS We identified 4671 adults newly diagnosed with COPD exacerbations and 9342 adults newly diagnosed with COPD without exacerbations during 2000-2008 using Taiwan's National Health Insurance Research Database. A comparison cohort of 18684 adults without COPD, matched by age and sex, was randomly selected from the same dataset for the control group. Diabetes events during 2000-2013 were ascertained from medical claims during the follow-up period. Adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) of diabetes associated with COPD with or without exacerbations were calculated. We conducted another nested cohort study of 395516 patients with diabetes hospitalization during 2002-2013 and calculated adjusted odds ratios (ORs) and 95% CIs of histories of COPD and COPD exacerbations associated with adverse events after diabetes admission. RESULTS During the follow-up period, the incidences of diabetes for patients without COPD and for patients with COPD without or with exacerbations were 3.4, 4.1 and 7.4 per 1000 person-years, respectively (P < 0.0001). Increased risk of diabetes for patients with COPD without exacerbations (HR 1.09, 95% CI 1.02-1.17) and COPD with exacerbations (HR 2.18, 95% CI 1.88-2.52) was noted. Post-diabetes pneumonia (OR 3.28, 95% CI 3.13-3.43), intensive care admission (OR 1.32, 95% CI 1.26-1.39) and mortality (OR 2.06, 95% CI 1.88-2.25) were associated with COPD exacerbations. CONCLUSION Prevention and intervention strategies for diabetes and post-diabetes outcomes are needed for this susceptible population.
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Affiliation(s)
- Chao-Shun Lin
- Department of Anesthesiology, School of Medicine, College of Medicine, Taipei Medical University Hospital, Taipei, Taiwan
- Anesthesiology and Health Policy Research Center, Taipei Medical University Hospital, Taipei, Taiwan
- Department of Anesthesiology, Taipei Medical University, Taipei, Taiwan
| | - Chih-Chung Liu
- Department of Anesthesiology, School of Medicine, College of Medicine, Taipei Medical University Hospital, Taipei, Taiwan
- Anesthesiology and Health Policy Research Center, Taipei Medical University Hospital, Taipei, Taiwan
- Department of Anesthesiology, Taipei Medical University, Taipei, Taiwan
| | - Chun-Chieh Yeh
- Department of Surgery, China Medical University Hospital, Taichung, Taiwan
- Department of Surgery, University of Illinois, Chicago, United States of America
| | - Yi-Cheng Chang
- Division of Endocrinology, Department of Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Chi-Li Chung
- Division of Pulmonary Medicine, Department of Internal Medicine, Taipei Medical University Hospital, Taipei, Taiwan
| | - Hsin-Long Lane
- School of Chinese Medicine for Post-Baccalaureate, College of Medicine, I-Shou University, Kaohsiung, Taiwan
| | - Chun-Chuan Shih
- School of Chinese Medicine for Post-Baccalaureate, College of Medicine, I-Shou University, Kaohsiung, Taiwan
| | - Ta-Liang Chen
- Department of Anesthesiology, School of Medicine, College of Medicine, Taipei Medical University Hospital, Taipei, Taiwan
- Anesthesiology and Health Policy Research Center, Taipei Medical University Hospital, Taipei, Taiwan
- Department of Anesthesiology, Taipei Medical University, Taipei, Taiwan
| | - Chien-Chang Liao
- Department of Anesthesiology, School of Medicine, College of Medicine, Taipei Medical University Hospital, Taipei, Taiwan
- Anesthesiology and Health Policy Research Center, Taipei Medical University Hospital, Taipei, Taiwan
- Department of Anesthesiology, Taipei Medical University, Taipei, Taiwan
- School of Chinese Medicine, College of Chinese Medicine, China Medical University, Taichung, Taiwan
- Department of Anesthesiology, Shuan Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
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Suh S, Park MK. Glucocorticoid-Induced Diabetes Mellitus: An Important but Overlooked Problem. Endocrinol Metab (Seoul) 2017; 32:180-189. [PMID: 28555464 PMCID: PMC5503862 DOI: 10.3803/enm.2017.32.2.180] [Citation(s) in RCA: 104] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2017] [Revised: 03/20/2017] [Accepted: 03/27/2017] [Indexed: 01/08/2023] Open
Abstract
Glucocorticoids are widely used as potent anti-inflammatory and immunosuppressive drugs to treat a wide range of diseases. However, they are also associated with a number of side effects, including new-onset hyperglycemia in patients without a history of diabetes mellitus (DM) or severely uncontrolled hyperglycemia in patients with known DM. Glucocorticoid-induced diabetes mellitus (GIDM) is a common and potentially harmful problem in clinical practice, affecting almost all medical specialties, but is often difficult to detect in clinical settings. However, scientific evidence is lacking regarding the effects of GIDM, as well as strategies for prevention and treatment. Similarly to nonsteroid-related DM, the principles of early detection and risk factor modification apply. Screening for GIDM should be considered in all patients treated with medium to high doses of glucocorticoids. Challenges in the management of GIDM stem from wide fluctuations in postprandial hyperglycemia and the lack of clearly defined treatment protocols. Together with lifestyle measures, hypoglycemic drugs with insulin-sensitizing effects are indicated. However, insulin therapy is often unavoidable, to the point that insulin can be considered the drug of choice. The treatment of GIDM should take into account the degree and pattern of hyperglycemia, as well as the type, dose, and schedule of glucocorticoid used. Moreover, it is essential to instruct the patient and/or the patient's family about how to perform the necessary adjustments. Prospective studies are needed to answer the remaining questions regarding GIDM.
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Affiliation(s)
- Sunghwan Suh
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Dong-A University Hospital, Dong-A University College of Medicine, Busan, Korea
| | - Mi Kyoung Park
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Dong-A University Hospital, Dong-A University College of Medicine, Busan, Korea.
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Abstract
The population of older patients with inflammatory bowel disease (IBD) continues to grow, partly reflecting the aging global population in general. The debilitating effects of IBD compound age-related decrements in health and functional capacity, and make the medical management of older patients with Crohn's disease and ulcerative colitis distinctly challenging to clinicians. Here, we review the recent literature describing the pharmacologic management of IBD in this population, with focus on the safety, tolerability, and efficacy of common treatment options, such as steroids, immunomodulators, tumor necrosis factor-α antagonists, and integrin antagonists; surgical interventions in older patients are also discussed. Few studies have systematically and prospectively evaluated the clinical challenges in the medical management of IBD in this patient population, leaving a limited evidence base to which clinicians can turn to for guidance. Treatment patterns may thus be suboptimal. For example, prolonged steroid use in the elderly was found to be common, causing significant morbidity from side effects in a particularly vulnerable population. Finally, within the context of a limited evidence base, we discuss common treatment scenarios to define the parameters within which physicians can individualize care for older patients with IBD. Overall, older patients with IBD are at higher risk of adverse events and less treatment responsiveness compared with younger patients, underscoring the need for future studies to fully characterize appropriate treatment courses for this population.
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